This study aimed to identify modifiable risk factors for anastomotic leakage during the postoperative period to recognise areas of clinical practice that could be improved.

Medical charts of patients who underwent elective open anterior resection for rectal cancer over a 5-year period were reviewed retrospectively.

One hundred and twenty-four patients (64 males, mean age 68.0+/-9.0 standard deviation [SD] years) underwent an anterior resection for rectal cancer during the study period. Twenty-two (17.7%) patients had anastomotic leakage. Patients who were given more than 8000ml of intravenous fluid during the perioperative 72-hour period had a statistically significant increased risk of developing anastomotic leakage (odds ratio (OR) 3.20, 95% confidence interval (CI): 1.10-9.31, p=0.049) and the risk increased further when patients were given more than 8500ml of intravenous fluid (OR 3.86, 95% CI: 1.29-11.5, p=0.019). The incidence of anastomotic leakage was not influenced by baseline co-morbidity or tumour stage.

Perioperative intravenous fluid of more than 8000ml was associated with increased occurrence of anastomotic leakage. Vigorous monitoring of intravenous fluid use in the perioperative period may minimise this complication.

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Preoperative staging of colon cancer according to Swedish national guidelines implies imaging evaluation of the primary tumour, liver and lungs. Failure to adhere to these guidelines results in negative scorings in the national registration system. In the present study we report the extent of compliance to these guidelines.

Since 2007 clinical data on all patients diagnosed with colon cancer in Sweden is collected in a national database. This includes information on pre-therapeutic diagnostic imaging performed, pre-therapeutic TNM stage and data on treatment and follow-up. All patients diagnosed with colon cancer in Sweden 2007-2010 were included.

9083 (60.5%) of all patients had a complete pre-therapeutic radiological evaluation. 65.2% had a CT or MRI of the primary tumour, whereas over 80% had examinations of the liver and lungs. There were no difference related to sex, but more patients under 75 years had a complete evaluation. There were large differences between different regions; one region had performed a complete evaluation of 78.3% of the patients. The proportion of patients examined increased from 53.9 to 65.0 per cent during the study period. Elective cases were more frequently evaluated before treatment than those with an emergency presentation..

Most patients in Sweden had a complete pre-treatment imaging evaluation of the colon cancer with geographical and time dependant variations. The importance of these variations and correlation of pre- and postoperative TNM stage is warranted and such studies are ongoing.

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3-dimensional (3-D) anorectal high-resolution manometry (3D HRAM) is a new technique that can simultaneously provide physiological and topographic data. Our aim was to assess whether it can identify anal sphincter defects by comparing it with endoanal ultrasonography (EUS) considered as the gold standard.

An anal defect on 3D HRAM was defined as a continuous circumferential area over which the pressure was < 10 mmHg during the measurement of anal resting and voluntary contraction pressure. Inter-observer agreement was also assessed.

100 patients (93 females) with a mean age of 53.5±15.3 years were included. The positive diagnosis of an anal sphincter defect using 3D HRAM and EUS was in agreement 59.3% (kappa=0.419) of the time for the IAS and 55.9% (kappa=0.461) for the EAS. The inter-observer agreement for a diagnosis of an anal sphincter defect was 100% (kappa= 0.937) for the IAS and 95% (kappa=0.751) for the EAS. The intra-class correlation coefficient for the extent of the defect was 0.853 for the IAS and 0.651 for the EAS.

The preliminary results demonstrate some level of agreement in the diagnosis of anal sphincter defects between 3D HRAM and EUS, but insufficient for 3D HRAM to be adequately reliable using the criteria chosen. The excellent inter-observer agreement demonstrates, however, that 3DHRAM is reproducible and provides a new dimension for the evaluation of sphincter function.

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Colorectal cancer (CRC) is the second commonest cause of cancer death in Taiwan. Although numerous genes have been associated with tumorigenesis in colorectal cancer, only a few have been validated and used as biomarkers for predicting clinical outcome. The aim of this study was to analyze the association of APC gene inactivation and miR-21 expression with clinical outcome in CRC patients.

195 colorectal cancer patients were enrolled in a single medical center between 2003 and 2007. APC gene mutation and expression of APC and miR21 were analyzed by direct DNA sequencing and real-time RT-PCR. The primary outcome included 5-year overall survival, and univariate (Kaplan-Meier) and multivariate (Cox regression) analyses of prognostic factors.

The results showed that 66 (33.8%) of 195 tumour tissues contained an APC mutation. The predominant APC gene variations were deletion mutations (50.0%). APC gene expression was low in CRC and negatively correlated with miR-21 expression and gene mutation. In advanced-stage cancer, patients with APC mutation/high miR-21 had poorer overall survival rates than those with APC mutation/low miR-21, APC wild-type/high miR-21, and APC wild-type/low miR-21.

In Taiwan, down-regulation of the APC gene in CRC correlated with gene mutation and miR-21upregulation. APC mutation and miR-21 expression could be used to predict the clinical outcome of CRC, especially in patients with advanced disease.

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To report data supporting the development of tailored treatment strategies for rectal cancer.

A comprehensive review of the literature on the impact of prognostic factors currently not included in international guidelines in rectal cancer management is discussed.

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for stage II and III disease. Long term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge of, and the prognostic impact of the circumferential resection margin, tumour grade, and venous invasion should be factored into the development of a treatment strategy.

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors should be the basis for treatment decisions. International guidelines should consider all known prognostic factors, both for long-term oncological and functional outcomes.

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Pudendal nerve terminal motor latency (PNTML) assesses distal innervation of the external anal sphincter (EAS) but it is insensitive to early nerve damage. We propose to extend the assessment of PNTML to the measurement of the compound muscle action potential (CMAP) of the EAS to understand its progressive denervation.

90 female patients with faecal incontinence were prospectively examined and compared with 36 asymptomatic women who acted as controls. PNTML was performed bilaterally and the muscle response analysed for CMAP to include amplitude, area and duration. Anorectal manometry was measured by a station-pull technique using a water-filled microballoon. SPSS Version 11.5 was used for statistical analysis.

In asymptomatic females the CMAP on the left side was greater in nulliparous (n=7) than parous (n=27, p<0.05) individuals. There was a positive correlation with maximum squeeze pressure and Area on the left side (p<0.05, r=0.397). In women with faecal incontinence, CMAP on the left side had a negative correlation with age (n=75, p<0.05), there was no correlation with parity or anorectal manometry. Nulliparous asymptomatic females had a greater CMAP (p<0.05) on the left side than asymptomatic parous women and parous women with faecal incontinence. Right side measurements were not conclusive.

CMAP demonstrated progressive denervation with age in women with faecal incontinence but did not reliably identify early signs of denervation in asymptomatic females. The area on the left side related to muscle function in asymptomatic females but not in women with faecal incontinence. CMAP can distinguish between parous women with faecal incontinence and nulliparous asymptomatic women but is not a useful test of EAS function.

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Surgical resection of a primary colorectal tumour remains the treatment of choice and offers the best chance of cure. However in some patients, resection is not achieved. There are few published data on this group of patients.. The aim of this study was to evaluate this group to determine the frequency and reasons for non-resection, and to analyse the subsequent management..

A retrospective review was performed using a Trust Colorectal Cancer Database and individual Electronic Patient Records. Patients that presented to our unit with a diagnosis of primary colorectal cancer managed by non-resectional intervention over a two-year period were identified,. Data analysed included: patient demographics, radiological staging, histological data, non-surgical therapy, tumour-specific complications and requirement for palliative surgical procedures.

A total of 671 patients were identified with primary colorectal cancer. One hundred and fifty six (23%) were managed without resection, following discussion at a multi-disciplinary team meeting,. Of 156 patients, histological confirmation was obtained in 131 (84%), with the remainder of diagnoses being based on unequivocal radiological imaging and/or operative findings. Complete radiological staging was achieved in 150 (96%) patients. The predominant reasons for non-resectional management were: advanced metastatic disease (66%), significant medical co-morbidity (19%), and patient refusal (6%). Fifty-nine of 156 patients (38%) subsequently received palliative chemotherapy, 9 (6%) radiotherapy, or 9 (6%) combination chemo-radiotherapy. Seventy-nine (51%) of 156 patients received no therapy other than best supportive palliative care, for reasons including significant medical co-morbidity (62%), and patient refusal (19%). Following the initial non-resection decision, 68 (44%) patients did at some point undergo some form of palliative intervention (stenting, stoma or bypass) for obstruction; 44 (28%) electively and 24 (15%) emergently.

Non-resectional management of patients with primary colorectal cancer is not an uncommon outcome following discussion at a multi-disciplinary meeting. In these patients, non-surgical palliation should be employed when necessary, though is, frequently limited by co-morbidity.. There also remains a need, however, for continued Subsequent urgical palliation is still required in a substantial proportion of cases.

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The sensation that the rectum remains or is functioning after abdominoperineal resection (APR) is called phantom rectum (PR). Its postoperative and long-term morbidity are not well documented. Informed consent may not include the risk and consequences of this condition. We assessed the incidence and morbidity of PR after APR.

Patients who underwent APR between 1/1/04 and 12/31/08 were identified. Preoperative radiation and operative reconstruction by vertical rectus abdominis myocutaneous (VRAM) flaps were noted. Patients were interviewed by telephone to assess the presence and timing of PR symptoms and their effect on quality of life.

Thirty-six of 80 patients who underwent APR were available for follow-up. Twenty three (64%) described PR symptoms including urgency to evacuate (22[61%]), sensation of faeces in the rectum (19 [52%]), and sensation of passing flatus (17 [48%]). Eleven (47%) reported having symptoms at less than 3 months after APR. Patients described their symptoms as “unchanged over time” (20 [56%]), “gradually decreasing and ultimately disappearing” (13 [35%]), or “worsening” (3 [9%)]. Preoperative radiation and laparoscopic approach were not associated with PR symptoms. Significantly more patients having a VRAM flap reported early PR symptoms (7/11 [64%] vs 4/25 [16%]) (p =0.008).

PR sensations were experienced by 23 [64%] of patients who underwent APR for rectal cancer. VRAM reconstruction was associated with early PR presentation. The possibility of PR should be discussed preoperatively in patients undergoing APR for anorectal neoplasm.

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The study assessed the impact on anorectal function of endoscopic mucosal resection (EMR) and transanal endoscopic microsurgery (TEM) of rectal adenoma.

Patients with a large (≥3 cm) rectal adenoma undergoing EMR or TEM were included. Self-reported faecal incontinence was assessed using the COREFO questionnaire and Wexner scale. Anorectal manometry was performed before and at 6 months after treatment to measure anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), the rectoanal inhibitory reflex (RAIR), rectal volumetry of first sensation (FS), first urge (FU), maximum tolerable volume (MTV)) and rectal compliance (RC).

Twenty four patients were included in the study including 11 (EMR) and 13 (TEM). The mean adenoma size was 51 ± 19 mm and the median distance from the anal verge was 3 (IQR 1-10)) cm. Follow-up data were available from 20 patients; one had died and three had undergone total mesorectal excision. Incontinence for liquid stool and Wexner score decreased significantly after treatment. In contrast, none of the measured parameters of anorectal motility (ARP, SP, SE, RAIR, RC) and perception (FS, FU, MTV) was affected by adenoma resection. No differences were found in baseline and follow-up incontinence and functional parameters between intervention groups, except for postprocedural ARP, which was lower after TEM than after EMR.

Continence in patients with a large rectal adenoma improved after EMR or TEM, probably due to decreased rectal mucus production. Anal sphincter pressure, rectoanal reflexes, rectal sensation and compliance were not affected by adenoma resection.

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This study examined the relevance of using a two sample quantitative immunochemical faecal occult blood test (iFOBT or FIT) at a high cut off stringency by the first population-based colorectal cancer (CRC) pilot screening programme in Ireland.

Approximately ten thousand individuals between the ages of 50-74 years were invited to perform two consecutive FITs. These were analysed in tandem using the OC-Sensor and participants with at least one positive result with a haemoglobin cut off for positivity at 100 ng/ml were offered colonoscopy.

A total of 5023 (52%) (2177 (43%) male; 2846 (57%) female) individuals with a median age of 64 years participated. At least one positive FIT test was detected from 514 (10%) individuals. From the 419 (82%) patients who proceeded to colonoscopy 17 (4%) had CRC and 132(33%) had an advanced adenoma. The detection rate for these screen relevant lesions was 3% (95% CIs = 2.5% - 3.5%) and the FIT positive + colonoscopy detection rate was 36% (95% CI = 31% - 40%). The numbers needed to colonoscope to find an advanced lesion was 2.8. The two test system detected four (23.5%) additional patients with CRC and 37 (28%) with an advanced adenoma compared with a single test.

The CRC miss rate estimated for a single test (23.5%) was unacceptably high when the goal was to maximize the discovery of advanced lesions in the initial screening round. We conclude that the two test protocol at a high cut off threshold is suitable to optimize FIT screening in Ireland.

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Minimal data is available on the role of pelvic exenteration in patients with recurrent squamous cell carcinoma (SCC) of the pelvic organs. This study aimed to highlight our experience of pelvic exenteration in patients with recurrent and re-recurrent SCC of the pelvic organs.

A retrospective review of all patients who underwent pelvic exenteration for recurrent SCC of the pelvic organs arising from the embryological cloaca from 1994 to 2010 was performed.

Twenty-four patients (median age 59, range, 27 – 79 years) underwent pelvic exenteration for recurrent SCC of the anus (18), cervix and upper vagina (2), lower vagina (1) and the vulva (3). Nine patients with anal SCC had undergone abdomino-perineal resection prior to pelvic exenteration. Ten (41.7%) patients underwent a complete pelvic exenteration procedure, while sacrectomy was performed in 13 (54.2%) patients. There was no 30-day inpatient mortality.An R0 resection was achieved in 15 (62.5%) patients. Three (12.5%) had R1 resections while 6 (25%) had R2 resections. In15 patients with an R0 resection, 7 (46.7%) developed metastatic disease at a median of 18 (range 10 – 131) months. After a median follow up of 26 (range 4 – 169) months, one- and two-year overall survival rates were 64% (95% confidence interval (CI), 44 – 84%) and 57% (95% CI, 35 – 79%), respectively.

Pelvic exenteration for recurrent SCC of the cloaca is safe and feasible even after previous salvage surgery. An R0 resection can be achieved in 62.5% of the patients with reasonable early survival though less than published recurrent rectal cancer studies.

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Ileocolic anastomosis is performed using a stapled or manual technique,but with either there is a risk of bleeding from the suture line. The aim of this study was to analyse retrospectively bleeding after different anastomotic technique.

Patients having elective right colectomy were divided according to the type of ileocolic anastomosis into Group I; circular double stapled end-to-side and Group 2; linear stapled side-to-side and Group 3; handsewn side-to-side anastomosis. Postoperative lower gastrointestinal bleeding (LGIB) was studied in the three groups. Uni- and multivariate analysis was performed to study risk factors for LGIB and need for postoperative allogeneic blood transfusion.

350 patients were included, 174 in Group I, 59 in Group 2 and 117 in Group 3. The postoperative LGIB rate was 4.9% and exclusively happened in Group I with five having severe anastomotic bleeding. Postoperative blood transfusion was indicated in Groups I, 2 and 3 of 19.0%,, 5.1% and 13.7%. In the five patients with severe bleeding four attempts of colonoscopic arrest were made achieving bleeding control in one. Angiographic embolization was successful in one patient. There were no procedure specific complications.

End-to-side circular double stapling ileocolic anastomosis seems to be related to an increased incidence of anastomotic bleeding and of postoperative blood transfusion compared with patients havine other techniques of ileocolic anastomosis.

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Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series was published. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early post-operative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

A literature search of the EMBSASE and MEDLINE databases between Aug 1991-Aug 2011 was conducted using keywords: laparoscopy, rectal cancer and post-operative complications. Data was analysed using linear regression ANOVA (analysis of variances) performed in Gnumerics software.

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in rate of any early post-operative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (p=0.01).

There was no evidence of a statistically significant change in early post-operative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of on-going RCTs, might show improved outcomes.

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National guidelines for colorectal cancer management aim to optimise cancer outcomes irrespective of postcode. However, in order to ensure equal performance of cancer services, variation in outcome must be monitored and intelligently assessed. In this study, detailed regional cancer registry data is used to quantify and explore reasons for variation in colorectal cancer outcomes at nine hospitals in East Anglia.

We analysed data on colorectal cancers registered by the Eastern Cancer Registry and Information Centre (ECRIC) between 1999 and 2005. Tumours were grouped by site in keeping with surgical resection. Multivariable Cox regression models were used to identify patient, disease and treatment variable effects on an individual's risk of death.

After adjusting for demographic, disease and treatment variables there was a significant difference in survival between hospitals in emergency admissions with cancer of the right colon, in elective admissions with cancer of the left, sigmoid or recto-sigmoid colon and in emergency admissions with cancer of the rectum. There were also differences between hospitals in terms of perioperative death, non-surgical management, and numbers of nodes examined. For rectal cancers, rates of anterior resection versus abdomino-perineal excision differed, as well as use of neoadjuvant radiotherapy.

Detailed analysis of demographic, disease and treatment factors are required when comparing the survival of individuals with colorectal cancer across hospitals. Results imply that cancer management was not consistent across East Anglia in 1999-2005 but the reasons for this are uncertain. Nevertheless, five-year age-standardised survival with colon cancer in the Anglia Cancer Network region is currently amongst the best in the UK.

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To investigate whether pre-treatment haemoglobin (Hb) levels act as a biomarker in management of patients with locally advanced rectal cancers.

We prospectively collected data on all patients within our cancer network with localised low rectal cancers treated with preoperative radiotherapy /chemoradiotherapy at Mount Vernon Centre for Cancer Treatment between March 1994 and July 2008. Pre-treatment Hb levels is assessed as an independent variable for the whole study sample and dichotomised at a value of 12g/dL. A multivariate analysis (MANCOVA) is conducted on parameters that had significant association on univariate (ANCOVA) and correlational analysis (Kendall tau / Pearson). Kaplan-Meier survival analysis and Cox proportional hazard models were used to determine significant prognostic markers. Statistical significance was set at 0.05.

A total of 463 patients (M:F 2:1; Median age 66 yrs, IQR 57–73) were included in the analysis. There was significant tumour response in terms of ‘T-stage’ (p <0.001) and ‘N-stage’ (p <0.001) regression with 17.6% of patients achieving pathological complete response. We found that pre-treatment Hb value is inversely related to the cranio-caudal vertical tumour length (p 0.02) and pre-treatment T-Stage of tumour (p 0.01). Patients with Hb levels of less than 12 g/dL and moderately differentiated adenocarcinoma of rectum were less responsive to neoadjuvant chemoradiation. In addition, local recurrence was more common in patients with pre-treatment Hb of less than 12g/dL (Hazard Ratio = 1.78), over a median follow up of 24 months but this was not statistically significant (p = 0.08).

Pre-treatment level of Hb might be used as a biomarker of rectal tumour morphology, response to neoadjuvant chemoradiation and risk of local recurrence.

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Prolonged ileus, low-grade fever, and abdominal discomfort are common during the first week after colonic resection. Undiagnosed anastomotic leak carries a poor outcome and computed tomography (CT) scan is the best imaging tool for assessing postoperative abdominal complications. We used a CT scan-based model to quantify the risk of anastomotic leak after colorectal surgery.

A case-control analysis of 74 patients who underwent clinico-radiological evaluation after colorectal surgery for suspicion of anastomotic leak was undertaken and a multivariable analysis of risk factors for leak was performed. A logistic regression model was used to identify determinant variables and construct a predictive score.

Out of 74 patients with a clinical suspicion of anastomotic leak, 17 (23%) had this complication confirmed following repeat laparotomy. In multivariate analysis, 3 variables were associated with anastomotic leak: 1) white blood cells (WBC) count>9x10⁹/L (OR=14.8); 2) presence of >500cc of intra abdominal fluid (OR=13.4); and 3) pneumoperitoneum at the site of anastomosis (OR=9.9). Each of these 3 parameters contributed 1 point to the risk score. The observed risk of leak was 0%, 6%, 31% and 100% respectively for patients with scores of 0, 1, 2 and 3. The area under the receiver operating characteristic curve for the score was 0.83 (0.72-0.94)

This CT scan-based model seems clinically promising in order to objectively quantify the risk of a leak after colorectal surgery.

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Although serum carcinoembryonic antigen (CEA) level is prognostic in colorectal cancer, the prognostic role of tumor CEA expression is unclear. The aim of this study is to identify the prognostic and surveillance roles of tissue CEA expression along with serum CEA concentration in patients curatively resected for colorectal cancer.

Between January and December 2003, two hundred ninety four patients who underwent curative resection for colorectal cancer were included in the study. Correlation of tissue CEA expression with overall survival (OS), disease-free survival (DFS) and elevated serum CEA concentration at tumor recurrence were analyzed.

Tissue CEA expression was positive in 215 patients (73.1%). CEA expression was an independent prognostic factor for OS (hazard ratio [HR]=2.537, 95% confidence interval [CI]=1.065-6.042, p=0.035) and DFS (HR=3.090, 95% CI=1.405-6.795, p=0.005). Serum CEA elevation at tumor recurrence was significantly lower in patients without than with tissue CEA expression (14.3% vs. 57.6%, P=0.045). Moreover, when patients were grouped according to a combination of serum CEA elevation and tissue CEA expression, those with tissue CEA expression and elevated serum CEA (group 3) had significantly poorer OS and DFS (p<0.001 each) than those without CEA expression and elevated serum CEA (group 1) and those with either tissue CEA expression or elevated serum CEA (group 2). OS (p=0.006) and DFS (p=0.027) were both significantly greater in group 1 than in group 2.

Tissue CEA expression is a prognostic factor in patients with colorectal cancer. Analysis of tissue CEA expression may be helpful in determining the clinical utility of serial measurements of serum CEA as surveillance in patients with curatively resected colorectal cancer.

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There is skepticism regarding anatomical rationale and Doppler guidance for ligation of haemorrhoidal arteries. The null hypothesis of this randomized controlled trial (RCT) was that there is no difference in pain following dearterialization or haemorrhoidectomy for grade III/IV internal haemorrhoids in a minimum of three quadrants.

Single-center, double-blind RCT. Patients allocated to dearterialization or haemorrhoidectomy. Grade III: prolapsing but reducible; grade IV: chronic nonincarcerated. Primary endpoint: pain. Patients with external component, acute incarcerated grade IV, or recurrent haemorrhoids not included. Interventions: dearterialization (with Doppler guidance and mucopexy) or haemorrhoidectomy. Main outcome measure: Brief Pain Inventory (BPI).

Twenty dearterialization patients were comparable to 20 haemorrhoidectomy patients for age (p=0.107), BMI (p=0.559), race (p=0.437), ASA (p=0.569), co-morbidities (p=0.592), grade (p=0.096), quadrants (p= 0.222), FIQOL (p=0.388), coping (p=0.532), depression (p=0.505), embarrassment (p=0.842), SF-12 physical (p=0.337), mental components (p=0.396), constipation (p=0.628) scores. Dearterialization patients had shorter operative time (36 vs. 54 min, p=0.043) with less pain (p=0.011) and urinary retention (p=0.012). Dearterialization patients had first bowel movement earlier (1.3 vs. 4.6 days, p=0.001), less pain (p=0.011), lower pain intensity (p=0.001). Narcotic requirements were reduced in dearterialization patients (25 vs. 100%, p=0.001), with less medication (4.9 vs. 112 pills, p=0.001), and shorter regimen (0 vs. 7 days, p=0.001). BPI did not differ on day 1, 3, 5, 7, 14 except for less pain in dearterialization patients. At 3 months, symptomatic relief was same with no differences in BPI, FIQOL, SF-12.

Compared to haemorrhoidectomy, dearterialization led to less pain in grade III/IV hemorrhoids.

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Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain.

Ten patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for three weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a >50% reduction in pain score.

Ten patients recruited, 5 were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had >50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of five-years, the remaining 2 patients obtained no benefit, and had their devices removed or deactivated. These 2 patients both had depression that was also not improved by SNS.

This study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.

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The diagnosis and treatment of ulcerative colitis (UC) is traditionally the realm of gastroenterologists. However, UC symptoms overlap with those of bowel cancer and patients may be initially referred to colorectal surgery clinics. The aims of this study were to define which speciality most frequently diagnoses UC and to determine if there were differences in management between the two specialities.

Demographics, presenting symptoms and clinical management of patients with newly diagnosed UC were determined and compared by specialty clinic of initial referral. Histopathology reports and clinic letters were reviewed to identify patients newly diagnosed with UC at a large university teaching hospital from January 2007 to January 2012

Patients were more commonly referred to the colorectal surgeons (74 versus 41 patients) than gastroenterologists. Patients referred to gastroenterology were younger (36.0 versus 59.6 years, P<0.01) but there were no significant differences in gender, presenting symptoms or disease extent. Rigid sigmoidoscopy +/- biopsy was more commonly performed in colorectal clinic (93.2% versus 31.7%, P<0.01). There was a significantly shorter delay in starting disease-specific treatment for those patients referred initially to colorectal surgery (13.8 days versus 33.6 days, P=0.01). Performing rigid sigmoidoscopy in clinic was associated with starting disease-specific treatment at this visit.

Patients with first presentation UC are more commonly seen in colorectal surgery clinics where ridgid sigmoidoscopy is more frequently undertaken, allowing earlier commencement of UC treatment.

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Sphincter saving rectal cancer management affects anorectal function. This study evaluated persisting anorectal dysfunction and its impact on patients’ well-being.

Seventy-nine patients with a follow-up of 12 - 37 (median 22) months and seventy-nine age- and sex-matched control subjects completed questionnaires.

The median number of diurnal bowel movements was 3 in patients and 1 in controls (p<.0001). Nocturnal defecation occurred in 53% of patients. The median Vaizey score was 8 in patients and 4 in controls (p<.0001). Urgency without incontinence was reported by 47% of patients and 49% of controls (p=0.873), soiling by 28% of patients and 3% in controls (p<0.0001), incontinence for flatus by 73% of patients and 49% of controls (p=0.0019), incontinence for solid stools by 16% of patients and 4% of controls (p=0.0153). Incontinence of liquid stools occurred in 17 of 20 patients and 1 of 5 controls who had liquid stools (p=0.0123). Incontinence for gas, liquid or solid stool occurred once or more weekly in 47%, 19% and 6% of patients respectively. Evacuation difficulties were reported by 98% of patients, but also by 77% in controls. Neoadjuvant radio(chemo)therapy adversely affected defecation frequency and continence. Incontinence was associated with severe discomfort in 50% of patients, severe anxiety in 40%, and severe embarrassment in 48%.

Anorectal dysfunction is a frequent problem after management of rectal cancer with an impact on the wellbeing of patients.

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The study aimed to determine whether Helicobacter pylori infection is associated with colorectal adenocarcinoma and to quantify the extent of the risk.

A literature search was performed to identify studies published between 1995 to 2012 for relevant risk estimates. Fixed and random effect meta-analytical techniques were conducted for colorectal adenocarcinoma and adenomatous polyp.

Twenty seven case-controlled studies involving 3450 adenocarcinoma patients, 1304 adenomatous polyp patients and more than 4000 controls were included. Helicobacter pylori was associated with an increased risk of colorectal adenocarcinoma and adenomatous polyp (OR: 1.24, 95% CI: 1.12–1.37, P = 0.66 and OR: 1.87, 95% CI: 1.53–2.28, P = 0.81). There was a significant association between the CagA–positive strain and adenocarcinoma risk (OR: 1.22, 95% CI: 1.08–1.37, P = 0.05). In addition, there was an increased risk of tubular adenoma and villous adenoma formation (OR: 3.06, 95% CI: 1.98–4.73, P = 0.14 and OR: 2.05, 95% CI: 0.84–4.97, P = 0.86).

The meta-analysis suggests a promoting effect of Helicobacter pylori on the risk of adenocarcinoma.It also suggests that Helicobacter infection might have its influence at the start of the adenomatous polyp disease sequence.

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Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers

Clinicohistopathological data from fifty pretreatment anal carcinomas biopsies were collected. Immunohistochemical analysis with antibodies against Ki67, p53, Epidermal Growth Factor Receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinical-pathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients

All patients had undergone synchronous radio-chemotherapy; Tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumor expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) of patients presenting with a YKL-40/EGFR negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease free survival. Tumour grade significantly correlated with DFS only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome

YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy.

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The study included an investigation of factors determining suboptimal adjuvant chemotherapy t of patients diagnosed with stage III colon cancer.

All 606 patients diagnosed with stage III colon cancer between 2006 and 2008 in the western part of the Netherlands were included. Patient (gender, age, comorbidity, socioeconomic status (SES)), tumour (location, stage, grade) and treatment factors (emergency surgery, laparoscopic surgery, reoperation, hospital stay, multidisciplinary meeting) were examined in logistic regression analyses predicting a complicated postoperative period and omission, delay and discontinuation of adjuvant chemotherapy.

Overall, 27% of all patients experienced a complicated postoperative period, which was independently associated with emergency surgery, older age, multiple comorbidity, male gender and poor tumour grade. Of patients who survived this period, 60% received chemotherapy. Chemotherapy was omitted more often in females, elderly, patients with stage IIIB, reoperation, prolonged hospital stay and (borderline) after open surgery. Of patients who received chemotherapy, 86% started within 8 weeks after surgery. Patients with a higher SES, reoperation and prolonged hospital stay had a higher probability of a delayed start. Sixty-seven percent of patients completed their chemotherapy. For females, elderly and patients with prolonged hospital stay a higher probability of discontinuation was noted.

Age was the most important predictive factor for receiving adjuvant chemotherapy. However, at all ages, complicated postoperative recovery negatively influenced the administration of chemotherapy to stage III colon cancer patients, as well as a timely start and completion of chemotherapy.

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The short term outcome was examined of perineal vertical rectus abdominis myocutaneous (VRAM) flap reconstruction following abdominal perineal excision (APE).

Retrospective case note review of all patients undergoing APE and primary vertical rctus abdominal muscule (VRAM) reconstruction between July 2001 and February 2012 in a District General Hospital tertiary referral centre for APE. Complications were categorised using the Clavien-Dindo classification, which grades complications from I-V in order of increasing severity.

Fift five consecutive patients (31 male, median age 65 (38-84) years underwent APE with VRAM flap reconstruction, 15 for anal cancer and 40 for rectal cancer. Median length of stay was 11 days but was significantly shorter in the laparoscopic group compared to the open group (8 vs. 12 days; p<0.01) and in patients who did not experience a had no complication (p<0.05). Four (7%) patients had major complications (Grade 3 and above) directly related to the flap or donor site.

VRAM reconstruction of the perineum can be safely performed following APE with results that compare favourably with other techniques. Most flap complications are minor, although these are still associated with an increase in the length of hospital stay.

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The existing evidence on the relationship between Helicobacter pylori infection and the risk of colorectal neoplasia is inconsistent. We conducted a systematic review with a meta-analysis to explore this relationship and to determine whether the relationship varies according to the study characteristics.

We searched the PubMed database and the reference lists of pertinent articles published up to July 2012. Summary odds ratios (ORs) with their 95% confidence intervals (CIs) were estimated using a random-effects model.

Twenty-seven studies including 3792 cases of colorectal adenoma (CRA) and 3488 cases of colorectal cancer (CRC) were identified. Overall, H. pylori infection was associated with an increased risk of CRA (OR = 1.66, 95% CI 1.39-1.97, I² = 54.3%) and CRC (OR = 1.39, 95% CI 1.18-1.64, I² = 35.8%), although there was significant heterogeneity among the studies. Subgroup analysis revealed that the positive correlation did not differ by sex, geographic variation, or subsite of neoplasia, but might vary by the method of detection of H. pylori. The study was underpowered to determine the risk of colorectal neoplasia associated with CagA-positive H. pylori.

This meta-analysis demonstrates a positive association between H. pylori infection and the risk of colorectal neoplasia.

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Locally advanced fixed T4 rectal cancer has a poor prognosis and no standard treatment strategy. The aim of this study was to investigate safety and efficacy of neoadjuvant chemoradiotherapy using hypofractionated radiotherapy combined with local hyperthermia, capecitabine, oxaliplatin, metronidazole.

Radiotherapy was given to a total dose of 40 Gy in 10 fractions. Capecitabine 650 mg/m2 bid was given on days 1-22 and intravenous oxaliplatin 50 mg/m2 was administered on days 3, 10, 17. Local hyperthermia 41-45°C during 60 minutes was performed on days 8, 10, 15, 17. Metronidazole 10 g/m2 was administered per rectum on days 8 and 15. Surgery was carried out within 6-8 weeks after neoadjuvant treatment. The primary endpoint was R0 resection rate. Secondary endpoints included 2-year disease-free survival, 2-year overall survival, local recurrence rate, grade III-IV tumour regression (Dworak), treatment toxicity.

From July 2006 to February 2011, 64 previously untreated patients were enrolled. R0 resection was carried out in 59 (92,2%). Five (7,8%) remained inoperable. Seven (10,9%), patients had grade IV and 30 (46.9%) had grade III regression. The main grade III toxic events included diarrhoea (15.6% [n=10]), vomiting (3,1% [n=2]), proctitis (3,1% [n=2]) and skin reaction (1,6% [n=1]). Only one(1.6%) patient had grade IV diarrhoea and vomiting. The median follow-up was 24.9 months. Two-year overall survival was 91% and 2-year disease-free survival was 83%.

Hyperthermia combined with chemotherapy to produce radiosensitization for locally advanced fixed primary rectal cancer is followed by a high R0 resection rate, with toxicity comparable to standard regimens.

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Current British guidelines recommend surveillance colonoscopy at 12 months for individuals found to have ≥5 adenomas or ≥3 adenomas of which at least one is ≥1cm in size. This study describes the yield of surveillance colonoscopy in this group and explores patient and clinical factors which may be associated with the presence of advanced adenomas or cancer at surveillance.

Data were retrieved from the national database of the NHS Bowel Cancer Screening Programme. The detection of advanced colonic neoplasia (ACN) was used as the main outcome variable. Multivariable analysis was used to analyse relationships between patient factors (age, gender, body mass index, smoking and alcohol use) and clinical findings (number, size and nature of adenomas detected during index colonoscopy) with the outcome variable.

1760 individuals were included in the study. The yield of ACN at 12 month surveillance was 6.6% (116/1760) of which 14/1760 (0.8%) had colorectal cancer. 9/14 (64.3%) of these cancers were Dukes stage A at diagnosis.

The presence of a villous adenoma or a right sided adenoma at screening colonoscopy was associated with odds ratios of 1.98 (95% CI 1.11-3.53, p=0.012) and 1.76 (1.13-2.74, p=0.020) respectively for detection of ACN at surveillance.

12 month surveillance colonoscopy is necessary in this group of patients. The presence of villous or proximal lesions at baseline is associated with increased risk of ACN at surveillance. Site and histological type of baseline lesions may be relevant to determining the surveillance interval.

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Despite increasing recognition of ulcerative colitis (UC) in Asia in recent decades, reports on the occurrence of colorectal neoplasia (CRN) in UC are scarce and surveillance for this complication is not routinely practiced in this region. We aimed to assess the outcome of a newly initiated pilot screening program for screening CRN among UC patients in India.

In this prospective study from an academic hospital setting, UC patients at high risk of CRN were offered screening by magnifying chromo colonoscopy and the frequency of neoplastic lesions was assessed.

29 (70.7%) of 41 eligible patients [a median age of 46 (IQR 36-54.5) years; 17 (58.6%) male] enrolled for surveillance; 41 colonoscopies were undertaken over 42 months. The median disease duration was 10 (IQR 7.5-14.5) years. Sixteen (55.1%) had extensive colitis. On initial screening, low grade dysplasia (LGD) was seen in 5 (17.2%) and high grade dysplasia (HGD) in 3 (10.3%). Of the latter 3, one accepted proctocolectomy immediately, one underwent surgery for adenocarcinoma, and one refused surgery.. Twelve follow up colonoscopies in 9 patients revealed 3 new LGD.

HGD and subsequent adenocarcinoma can be detected with careful follow up in Indian patients with longstanding UC but acceptance of surveillance and subsequent therapy are suboptimal. We found evidence that screening and surveillance programmes are useful for detecting neoplasias in UC, and need to be customized for this region.

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Safety and survival were investigated in patients treated according to expaned surgical indications for colorectal hepatic metastases.

A retrospective analysis of all consecutive patients who underwent resection of colorectal hepatic metastases at Zhongshan Hospital from 2000 to 2010 was conducted. The patients were divided into two groups based on a change in the surgical indications introduced in 2005. Patients in Group I underwent hepatic surgery between 2000 and 2004, and those in Group II between 2005 and 2010. The clinicopathological data and survival rates of both groups were analyzed.

There were 530 patients who underwent hepatic surgery between 2000 and 2010. After the expansion of surgical indications, the rate of surgical resection rose from 25.1% to 35.1% (P < 0.05). There was no significant difference in perioperative mortality (2.2% vs. 0.9%) or morbidity (20.9% vs. 29.8%). Recurrence occurred in 27.5% and 36.7%, in Groups I and II and 5-year overall survival was 43% and 49% (not significant).

Expanding the indications for surgical resection of hepatic metastases increased the resection rate but had no significant effect on survival.

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The National Bowel Cancer Awareness Campaign (“Be Clear on Cancer”) was launched by the UK government in January 2012, encouraging people with bowel symptoms to present to primary care. Our aim was to evaluate the impact of the campaign on colorectal services in secondary care.

Suspected cancer 2-week-wait (2WW) patients 3 months before and 3 months after the launch of the campaign were included. Demographics, reason for referral, investigations performed, cost analysis and eventual diagnoses were collected.

Three hundred and forty-three patients (median age 70 (36-100) years, 194 (57%) females) were seen and investigated in the 3 months prior to the launch of the campaign at an average cost of £575 per patient. Twenty-seven (8%) were diagnosed with lower gastrointestinal cancer and 29 (8%) with polyps. In the 3 months following the launch, 544 patients (median age 68 (30-92) years, 290 (53%) females) were reviewed (59% increase; p=0.004). The “did not attend” (DNA) rate fell from 10% to 1%. Thirty-two (6%) patients were diagnosed with a lower gastrointestinal cancer and 20 (4%) with colorectal polyps. The cost per colorectal cancer detected rose from £7,585.58 before the campaign to £9,662.72 post launch (p=0.04).

The “Be Clear on Cancer” campaign has substantially increased the number of referrals under the 2WW rule, but mainly in the worried well. This has increased demands on both resources (59% more tests) and finance. Cost per cancer detected rose by 27% with no increase in funding to support the increased activity.

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Colorectal cancer (CRC) is the fourth most common carcinoma in China. For economic reasons, a national colorectal cancer registry system has not been established and a large scale screening programme has not yet been implemented. Therefore, accurate statistical data concerning the incidence of colorectal cancer covering the whole country cannot be obtained. In China, the majority of hospitals in central cities and even in county hospitals are able to provide medical care for CRC patients. Due to socioeconomic disparities, medical conditions and skill levels, there is a wide variation in the treatment. Most oncologists make their clinical decisions based on the National Comprehensive Cancer Network (NCCN) guidelines although some domestic guidelines are now available. In October 11, 2011, the China Ministry of Health released the National Guideline of colorectal cancer treatment. This will give a degree of standardization of the treatment of CRC nationwide and will ensure that higher quality care will be available, especially in rural areas. Owing to language difficulties, research on CRC in China has only had a limited exposure in the international literature, due in some part to lack of understanding of the current position in the country. Chinese colorectal surgeons urgently need to exchange their knowledge and experience with international colleagues. In this article, the current situation regarding surgical treatment of rectal cancer in China is summarized.

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The study evaluated function and quality of life (QoL) in all patients having restorative proctocolectomy (RPC) in Denmark for ulcerative colitis (UC) from 1980 to 2010. Inclusion of all patients in one country has never previously been achieved.

All patients who had had a restorative proctectoly in Denmark from the rirst to the last case in 2010 were studied. A cross sectional questionnaire survey was performed and function and QoL were assessed using a standardized questionnaire, the Short Form 36 (SF36) and the inflammatory bowel disease questionnaire (IBDQ).

The median duration of follow up was 11 (1-30) years. Apart from deaths, pouch failures and research protection, data on function and QoL were obtained in 1047 (85%) of 1229 patients who had a functioning pouch at the time of the investigation. More females experienced urgency than males (56% versus 44% [p=0.0021]). The median number of bowel movements/24 hours was seven (1-23) in females and six (1-20) in males (P<0.001). Pad usage was more frequent among females than males (62% versus 38% [p<0.001]). A higher incidence of major incontinence (p=0.009) and use of pads (p=0.01) was found among patients who had been operated on 21-30 years than 11-20 years previously. The prevalence of urgency was higher in patients operated on at 0-10 years compared with 11-20 years previously (p=0.009). The total IBDQ score was higher in males than females (p<0.001). Males scored higher in five of eight SF36 domains (p<0.001).

Females had more urgency, frequency of defaecation and pad usage. This was associated with a reduced QoL. RPC nevertheless resulted in good function and a high degree of satisfaction in most patients.

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Little is known about patterns of recurrence in obstructing colon cancer (OCC) at a population level. The aim of this study was to determine the risk of recurrence following potentially curative surgery in OCC compared with that in uncomplicated CC.

Data was obtained from the population-based digestive cancer registry of Burgundy (France). Local and distant failure rates were calculated using actuarial methods. A multivariate analysis was performed using a Cox model.

OCC represented 8.5 per cent of all colon cancers resected with curative intent (n=3375). The 5-year cumulative local recurrence rate was 14.2% for OCC and 7.6% for non-obstructing CC (p=0.003). In the multivariate analysis, obstruction was an independent risk factor for local recurrence (HR: 1.53 [1.01-2.34], p=0.047). The risk of local recurrence increased with advanced stage and age at diagnosis. The 5-year cumulative rate for distant metastases was also higher in OCC than in non-obstructing CC (36.1% vs. 23.1%; p<0.001). The relative risk of distant metastasis was borderline significant in the multivariate analysis (HR: 1.25 [0.99-1.59], p=0.057). Stage at diagnosis, macroscopic type of growth, period of diagnosis and sex were also significant prognostic factors. Age and subsite were not significant in the multivariate analysis.

It is possible to conduct special surveys in population-based registries to determine the recurrence rate of CC. Recurrence remains a substantial problem and is more frequent in OCC than in non-obstructing colon cancers. Efforts must be made to diagnose CC earlier. Mass screening is a promising approach.

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Surgical site infection (SSI) is a common complication following ileostomy closure (IC) with a frequency of up to 40%. This prospective randomised controlled trial was initiated to compare two surgical techniques closing the wound following IC: direct suture (DS) versus purse string suture (PSS). The primary endpoint was the SSI rate. Secondary endpoints were cosmetic outcome (using two validated scales POSAS and BIQ) and the influence of other factors on the SSI rate.

A total of 99 patients were screened. 84 patients were then included in this study. Forty-three patients were randomised into the PSS group, 41 into the DS group. Follow-up was performed within 3 days following surgery, at discharge, and 30 days and 6 months after the operation.

In the PSS group there were no cases of SSI compared to 10 cases (24%) in the DS group (p= 0.0004). There were no statistically significant differences in cosmetic outcome between the two groups. No other statistically significant factors influencing the incidence of SSI could be identified.

The rate of SSI is significantly lower following PSS than DS, with a similarcosmetic outcome.. Purse sting suture closure should be considered as standard of care for wound closure after ileostomy reversal.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The aim of the study was to evaluate factors affecting postoperative outcomes after laparoscopic total abdominal colectomy (TAC) with end ileostomy (EI) for ulcerative colitis (UC).

Patients undergoing laparoscopic TAC/EI for severe UC/indeterminate colitis during 1998-2010 in our institution were retrospectively identified from a prospectively established database. Demographics, disease characteristics and perioperative outcomes were recorded. Associations between the 30-day postoperative outcome and patient, disease and treatment-related variables were assessed using univariate and multivariate logistic regression models.

204 patients (105 males, median age 35.5 years) were identified. The conversion rate was 4.4%. Median blood loss and operation time were 100 ml and 185 minutes. Length of hospital stay was 5.8 ± 4.4 days. Overall postoperative morbidity, reoperation and readmission rates were 40%, 7% and 17%. Preoperative treatment with high steroid doses was significantly associated with postoperative morbidity on multivariate analysis (P =0.011). Univariate analysis showed that lower preoperative BMI, haemoglobin, serum albumin level, and pancolitis were associated with reoperation, of which a lower BMI (P =0.043) was also independently significant on multivariate analysis. No specific factor was significantly associated with readmission.

Preoperative clinical deterioration is associated with an adverse outcome after laparoscopic total abdominal colectomy for ulcerative colitis.

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Laparoscopic colorectal surgery is technically demanding and requires supervised training. This paper examines the short-term outcome following a component-based training in laparoscopic colorectal surgery.

Surgical outcome following laparoscopic colorectal resection was recorded on a prospective database. Cases were divided into three groups; including those performed by the fellows, those completed by the consultant and those completed by a combination of both consultants and fellows. Analysis of data was carried out for all colorectal resections and also for the subgroup of colorectal cancer patients.

511 cases were examined between June 2006 and January 2011. There was no statistically significant difference in operating time between fellows and consultants but the operating time was significantly longer for those procedures where both the consultants and fellows performed components of the operation. Conversion rate, post operative morbidity, recovery and length of stay were similar for all three groups for the whole patient cohort and also the subgroup of cancer patients. In the cancer subgroup, there was no difference in the pathological stages across the 3 groups.

Closely supervised training in laparoscopic colorectal surgery is not associated with any adverse effect on the short-term outcome.

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First-degree relatives (FDR) of patients with colorectal cancer (CRC) have an increased CRC risk. Few studies have addressed if adenoma and advanced adenoma risk is increased among individuals with family history of CRC aged 40-49 years.

To define prevalence and location of adenoma, advanced adenoma and CRC according to age in asymptomatic individuals with family history of CRC.

Retrospective study of asymptomatic FDR of CRC patients, aged 40 to ≥70 years, undergoing first screening colonoscopy over a three year period .

Among 464 individuals studied, adenoma and advanced adenoma prevalence was 18.1% and 6.4%, respectively. According to age intervals, prevalence of adenoma and advanced adenoma was 14% and 3.5% in 40-49 age group, 14.4% and 6.3% in 50-59 age group, 27% and 8% in 60-69 age group, 25% and 14% in ≥70 age group, with no significant difference among the four groups. No difference in lesion location was found, with similar numbers of pre-neoplastic lesions was found in right and left colon. CRC was diagnosed in three subjects (0.64%), one of them in 40-49 age group.

In our population of FDR of CRC patients aged 40-49 years, prevalence of adenoma and advanced adenoma was similar to that observed in older subjects with the same CRC risk. Our data support the current indication to perform screening colonoscopy earlier than 45 years in subjects at high CRC risk.

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Biomarkers have been utilized for prognosis in colorectal cancer, relatively few have been identified. We compared the prognostic value of serum alkaline phosphatase (ALP), lactate dehydrogenase (LDH), and γ-glutamyl transpeptidase (GGT) with carcinoembryonic antigen (CEA) and carbohydrate entigen 19-9 (CA 19-9) in patients with metastatic colorectal cancer (mCRC).

Blood samples were collected from 239 patients with mCRC presenting between 2005 and 2010 in the Sun Yat-sen University Cancer Center.

CEA (p<0.001), CA19-9 (p<0.001), GGT (p<0.001), ALP (p<0.001) and LDH (p=0.001) were statistically significant prognostic factors of overall survival (OS). CEA (p=0.002) and GGT (p=0.021) were validated as independent predictors. On univariate analysis CEA (p=0.003), CA19-9 (p=0.006), GGT (p<0.001) and ALP (p=0.001) were statistically significant predictive factors of progression free survival (PFS) in patients having first-line chemotherapy. CEA (p=0.011) and GGT (p=0.027) were independent. GGT (p=0.001), ALP (p=0.016) and LDH (p=0.039) levels were correlated with the tumour response rate assessed by computerized tomography (CT), while CEA (p=0.724) and CA19-9 (p=0.822) were not. There was a statistically significant difference in OS (p<0.001) and PFS (p<0.001) among patients who had elevations of both CEA and GGT compared with those having only one or neither elevated.

Among GGT, LDH, and ALP, only GGT plays an independent role with CEA in predicting OS and PFS in mCRC. When coupled with CEA, GGT may lead to improved prognostic predictors.

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Human papillomavirus (HPV) infection is associated with cervical cancer, but whether it is involved in colorectal carcinogenesis is controversial. We conducted a meta-analysis to evaluate the association between HPV and colorectal adenocarcinoma.

A search of the MEDLINE database was performed using the MESH terms “HPV”, “human papillomavirus”, and “colon cancer”, “rectal cancer”, “colorectal cancer”. The prevalence of HPV infection in colorectal cancer was estimated by pooling data from 16 studies (involving 1436 patients) published up to July 2012, taking into consideration methodological heterogeneity between studies. The association of HPV and colorectal cancer risk was estimated from case-control studies.

HPV prevalence was 31.9% (95% CI:19.3% to 47.9%). It was lowest in Europe (14.1%, 95% CI: 4.9%-34.1%) and highest in South America (60.8%, 95% CI = 42.7%-76.4%). Eight studies presented results of HPV typing in 302 HPV-positive colorectal carcinomas. HPV18 was the virus more frequently found in Asia 73.34% (95% CI 44.9 -90.7%) and Europe, (47.3% [95% CI 34.5 - 60.4]) of colorectal cancer cases. In contrast, HPV16 was the virus more prevalent in tumours from South America (58.3% [95%CI 45.5 -69.9%]). The analysis of five case–control studies showed AN increase in colorectal carcinoma risk with HPV positivity (OR 10.04 [95% CI 3.7 - 27.5]).

The results provide quantitative evidence for an association between HPV infection and colorectal cancer risk.

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Resection of the primary tumour in patients with stage IV colorectal cancer may be performed for related local symptoms to avoid future tumour-related complications whilst on systemic treatment. We compared the safety and efficacy of laparoscpic and open colectomy in this patient group.

Pubmed, Medline and Cochrane library were searched in the English literature for studies between January 2000 to October 2012 dealing with the laparoscopic resection of the primary tumour in Stage IV disease. Single-arm laparoscopic studies were systematically reviewed. Prospective and retrospective studies were included for meta-analysis. Endpoints include safety, complications, mortality an cancer specific outcome including 5-year and median survival.

Eleven studies comprising 1165 patients undergoing palliative laparoscopic colectomy for stage IV colorectal cancer were included. Five studies were comparative studies of laparoscopic and open colectomy. The former took longer (Pooled mean difference (MD) = 41.52; 95% CI = 11.47 to 71.56; Z = 2.71; p = 0.007), but resulted in shorter length of stay (Pooled MD = -2.41; 95% CI = -3.84 to -0.99; Z = 3.32; p = 0.0009), with fewer postoperative complications (pooled odds ratio = 0.53; 95% CI = 0.32 to 0.87; Z = 2.51; p = 0.01) and less estimated blood loss (Pooled MD = -47.71; 95% CI = -80.00 to -15.42; Z = 2.90; p = 0.004). Median survival ranged between 11.4 and 30.1 months.

Palliative colectomy performed laparoscopically is safe and is associated with a better perioperative outcome than open colectomy. The survival in this group of patients remains dependant on the response to systemic chemotherapy.

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Function, morbidityh and recurrence of symptoms after Robotic – assisted ventral mesh rectopexy (RVMR) and Laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFD) were compared.

Forty four patients operated for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, BMI, ASA status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared.

Operation time was longer in RVMR compared with LVMR (191+/-26vs163+/-39min; p=0.0002). RVMR had less blood loss (8+/-34 vs 42+/-88 ml; p=0.012) and fewer early complications (2%vs11%; p=0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (p= 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (p=0.692).

Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then laparoscopic VMR.

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Retrorectal tumours (RT) are uncommon and diagnosis and management remain difficult. The aim of the study was to evaluate the results of the surgical management of RT in our institution.

Medical notes of all patients operated for RT were reviewed. Clinical, radiological, surgical, histological data as well as morbidity and long term results were noted.

47 patients (34 women (72%), mean age 45.8 (range 17-85) years) underwent surgery for RT during 1997-2011. The commonest symptoms were pain (n=31) and suppuration (n=10). Thirty-nine (83%) patients underwent preoperative magnetic resonance imaging (MRI). Malignant lesions exhibited typical characteristics on MRI including heterogeneity (n=5, 83%), solid appearance (n=4, 67%), a low-T1 signal and high-T2 intensity (n=5, 83%), enhancement after gadolinium injection (n=5, 83%), irregular margin (n=4, 67%) and extension above S3 (n=5, 83%). A Kraske approach was used in 42 (89%) patients with resection of the coccyx in 25 (60%) and an abdominal or combined approach for the remaining five. Four patients developed complications (haematoma=2, abscess=2), but only one (haematoma) required reoperation. Histological examination showed 38 (80.9%) benign lesions. After a median follow-up of 71 (2-168) months, 5-year disease free survival was 75% for malignant lesions and 93.1% for benign lesions (p=0.023). Four (4/42; 9.5%) patients had moderate perineal pain after a Kraske approach, while no anal dysfunction was seen.

MRI was the most helpful investigation for retrorectal tumours. The posterior trans-sacrococcygeal approach is the procedure of choice for complete resection for most, especially for benign and cystic lesions without extension above S2.

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The study aimed to determine whether an ileostomy compromises nutritional, hydration and electrolyte status and bone mineral density.

Body weight(BW), body mass index(BMI) and fat and lean body mass(LBM) were measured in 60 patients with an ileostomy (14 small bowel resection [SBR]; 46 [NSBR] and in 60 age/sex matched normal controls. Measurement of plasma sodium(Na), potassium(K), calcium(Ca), magnesium(Mg), urea(Ur) and creatinine(Cr) and 24-hour urinary output of water, Na, K, Ca and Mg was made in 45 NSBR and 14 SBR ileostomists and in all the controls. 46 NSBR and 13 SBR ileostomists had bone mineral density (BMD) measurements of lumbar spine (LS) and femoral neck (FN).

The body weight of Ileostomists was less than controls, (median 67.8 [36.4-115.1] vs 77.7 [48.0-103.3] kg; p<0.05). BMI was also less (25.0 [14.3-43.0] vs 27.3 [20.2-32.2] kg/m²,p<0.05) with a lower LBM (47.8 [19.3-73.0] vs 52.9 [34.0-73.8] kg,p<0.05).The 24 urinary output of the ileostomists was lower than in controls (1380 [430-4690] vs 2000 [840-4440] ml/24 hours; p<0.05) suggesting some degree of dehydration. In 62.7% of ileostomists 24 hour urinary Na excretion was <100 mmol/d vs 16.7% in controls and ileostomists with lower urinary Na were more likely than ileostomists with normal sodium excretion to have a low BMI (23.9[14.3-33.0] vs. 28.4 [16.6-43.0] kg/m²; p<0.001) and LBM (44.1 [19.3-73.0] vs 59.5[36.6-67.9 kg; p<0.001). Respective 24 hour output of calcium was (2.2[0 – 6.1] vs 4.7[0-13] mmol; p<0.001), magnesium (2.0 [0 – 13.7] vs 3.9 [1.2 – 5.4[mmol; p<0.001) and BMD –Z-score LS -0.15(-2.0 to 5.2) vs. 0.3(-2.5 to 2.1), FN Z-score -0.5(-1.9 to 3.1) vs. 0.2(-1.2 to 1.4) both p<0.05.

Patients with an ileostomy tend to have low BW, BMI, LBM and BMD. They also tend to have low urine volumes, and some are depleted of Na, Ca and Mg. Abnormalities are greater in those with a lower urinary Na, and measuring this will identify ileostomists at risk of sodium depletion who will be benefitted by Na supplements.

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Anorectal melanoma is a rare neoplasm with poor prognosis. The aim of this study was to investigate what clinicopathologic factors predicted lymph node metastases and to investigate their association with survival.

Patients undergoing surgery with curative intent for primary anorectal melanoma in Fudan University Shanghai Cancer Center between 1989 and 2011 were studied retrospectively. Association between clinicopathologic factors and lymph node metastases and prognosis were determined.

Forty-three patients underwent a potentially curative resection with a median follow-up of 20 months; the 5-year overall survival rate (OS) was 29.6% with median overall survival of 28 months. Tumor diameter >3 cm was associated with mesorectal and mesenteric lymph node metastases (P=0.013). Perineural invasion (PNI)(HR 5.683; 95% CI1.978-16.328; P=0.001) was the only factor that independently predicted survival.

Tumor diameter was associated with mesorectal and mesenteric lymph node metastases; therefore, wide local excision (WLE) may not be appropriate for surgery with curative intent for patients with a tumor diameter ≥ 3cm. PNI was an important prognostic factor for anorectal melanoma.

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The overall risk of permanent stoma was determined in patients with extensive Crohn's colitis. An attempt was made to analyse whether biological drugs have modified the surgical approach in patients with anorectal involvement.

233 patients with Crohn's disease colitis operated on between 1995 and 2010 were reviewed retrospectively. Ffty one were treated before 2002 (Prebiological Era) and 182 after 2002 (Biological Era). The relationship was determined between the use of immunosuppressors, biological drugs, the presence of perianal disease and anorectal stenosis and the rate of permanent stoma formation.

In the Pre-Biological Era 23 (45.1%) patients without ano-rectal involvement underwent colectomy and ileo-rectal anastomosis, 17 (33.3%) with severe anorectal disease to proctocolectomy and 11 (21.6%) with anorectal involvement to abdominal colectomy with permanent ileostomy. In the Biological Era 73 (40.1%) patients without anorectal involvement underwent colectomy and ileo-rectal anastomosis, 9 (5%) with severe anorectal involvement to proctocolectomy and 100 (54.9%) with anorectal involvement to colectomy with permanent ileostomy. Of these 100, 75 have subsequently been treated with biological drugs with full regression of anorectal lesions in 81.3%. Rates of permanent stoma in the Pre-Biological and Biological Era were 60.8% and 19.2% (p < 0.001). Univariate and multivariate analysis showed that only the use of biological drugs was significantly associated with an increased rate of rectal preservation (p < 0.05).

The risk of a permanent stoma in patients with Crohn's colitis and anorectal involvement is significantly reduced with combined surgical and biological treatment.

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The morbidity of anastomotic dehiscence may be mitigated by a defunctioning stoma, but it is unclear if it is required for most low rectal anastomoses. Preoperative risk factors leading to anastomotic complications and the indications for faecal diversion have yet to be clearly defined.

Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-use file, patients were identified who underwent low anterior resection with anastomosis for cancer at the 211 participating hospitals in 2005-2008.

1791 patients underwent low anterior resection. Patients were subdivided into two groups based on the level of the anastomosis.1266 patients had a low pelvic anastomosis(LPA) and 525 a coloanal anastomosis (CAA). In the LPA group, 606 patients had a stoma and 660 had no stoma. There were no differences in wound complications, sepsis or septic shock. Patients that had a stoma were more likely to have post-operative acute renal failure (1.7%vs.0.5%,p=0.0485, OR3.674). In the CAA group, 352 had a stoma and 173 had no stoma. In patients without faecal diversion, there was a significantly greater incidence of sepsis (8.7% vs 3.7%, p=0.022, OR 2.47), septic shock (3.5% vs 0.57%,p= 0.018,OR 6.29) and need for re-operation (11% vs 1.7%, p=0.0001, OR 7.11). Hospital length of stay was significantly longer with CAA and no stoma.On multivariate analysis, not having a stoma with a CAA was a risk factor for serious postoperative morbidity.

While a defunctioning stoma with a coloanal anastomosis seems to protect from post-operative sepsis, septic shock and need for reoperation, it is likely that it is overused in rectal cancer surgery.

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The study compared efficacy, safety and tolerability of a low volume picosulphate/magnesium citrate preparation and PEG-ascorbic acid in a randomized clinical trial (RCT).

A multicentre randomized, single-blinded study was designed. Adult outpatients undergoing colonoscopy received either picosulphate/magnesium citrate (Group 1) or PEG-ascorbic acid (Group 2). Bowel cleansing was assessed using the Boston Scale (BBPS) and rated as adequate if >2 in each segment. Patient acceptance, satisfaction, and related symptoms were recorded.

285 patients were included. Preparation was adequate in 75.7% Group 1 and 76.5% in Group 2. The mean BBPS score for the entire and the right colon was comparable. 97.1% patients in Group 1 and 84.8% in Group 2 reported no or mild discomfort (p<0.0003) and 97.8% and 83.4% expressed their willingness to repeat the preparation (p<0.0001). Palatability was better in Group 1, whereas related symptoms occurred more frequently Group 2. Regardless of preparation, the split regimen was associated with better cleansing over the same-day method (OR 3.39; 95% CI 1.1-10.4, p=0.03). Other predictors of poor cleansing were comorbidity, discomfort during preparation, and incomplete (<75%) preparation.

Picosulphate/magnesium citrate and PEG-ascorbic acid are both effective for bowel preparation., Tolerability and palatability are better for picosulphate/magnesium citrate. A split schedule is associated to higher cleansing quality also for low-volume regimens.

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Evaluation of ≥ 12 lymph nodes (LNs) is recommended after surgery for colon cancer. A harvest of ≤ 8 is considered poor, but few reports have evaluated risk factors associated with a poor harvest. This aims of this study were to analyze the clinical, surgical, and pathological factors associated with poor LN harvest(LNH), total number of examined nodes, and the effect of LN number on stage.

All patients reported to the Norwegian Colorectal Cancer Registry during 2007 and 2008 who underwent were curative resection for stage I-III colon cancer were studied. Risk factors for poor LNH and the proportion of stage III disease were analyzed by univariate and multivariate analyses.

A total of 2,879 patients were included in the study. The median LNH was 14. Overall, 69.9% had ≥12 lymph nodes, and 14.4% had ≤ 8 LN (poor harvest). Multivariate analysis showed, male sex, age >75 years, sigmoid tumours, pT category 1-2, failure to use the pathology report template, and distance of ≤5 cm from the bowel resection margin were all independent factors for poor LNH. Age <65 years, pT category 3-4, and poor tumour differentiation were independent predictors of stage III disease. An increased LNH did not increase the proportion of patients identified as being LN positive at the ≤8, 9-11, and ≥12 LN levels.

Adequate LNH was achieved in the majority of curative colon cancer resections in this national cohort. Elderly, males, patients with sigmoid cancers, and a short distal margin were at increased risk of a poor LNH.

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Bowel dysfunction was assessed after low anterior resection with and without neoadjuvant therapy (NT) for rectal cancer using a novel symptom-based scoring system correlated with quality of life.

We identified all patients who underwent curative resection for rectal cancer in Denmark between 2001 and 2007. A questionnaire on bowel function and quality of life, including the recently validated ‘Low Anterior Resection Syndrome Score’ (LARS-score; range 0-42) was administered to recurrence-free patients in 2009. We used multivariate analysis to examine the association between major LARS (LARS-score≥30) and a number of patient and treatment-related factors.

Of 1087 eligible patients, 980 agreed to participate, and a final 938 patients were included in the analysis. Major LARS was observed in 41%. The use of NT (OR=2.48; 95% CI 1.73-3.55), long course chemoradiotherapy vs short-course radiotherapy (OR=0.90; 95% CI 0.44-1.87), total mesorectal excision (TME) vs partial mesorectal excision (PME) (OR=2.31; 95% CI 1.69-3.16), anastomotic leakage (OR=2.06; 95% CI 0.93-4.55), age≤64 years at surgery (OR=1.90; 95% CI 1.43-2.51), and female gender (OR=1.35; 95% CI 1.02-1.79) were associated with major LARS. No association was found between major LARS and the interval since surgery (OR=0.78; 95% CI 0.59-1.04) or neorectal reconstruction (colonic pouch vs. straight colorectal or side-to-end anastomosis (OR=0.96; 95% CI 0.63-1.46).

Severe bowel dysfunction is a frequent long-term outcome after resection for rectal cancer. Use of NT, regardless of a long or short course protocol, and TME (as opposed to PME) are strong independent risk factors for major LARS.

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There is no definitive consensus on the best treatment for pilonidal sinus. The Bascom cleft lift technique has been reported to produce successful results. This study presents the results of a modified cleft lift procedure in which the sinus tissue was excised and lower end of the incision is kept outside the intergluteal sulcus by extending the lower end of the incision laterally.

Between August 2010 and January 2012, 141 consecutive patients who presented with primary or recurrent pilonidal sinus disease were included in the study, which was conducted at a single tertiary academic medical centre. Prospectively collected data were recorded, including complications, pain score, satisfaction level, primary healing rate, length of hospital stay and early recurrence.

The mean operating time was 30 minutes and the mean length of hospital stay was 1.2 days. The most common surgical site complication was a collection followed by partial wound dehiscence and superficial infection. The primary healing rate was 88%, the mean time for functional recovery was 13 days and the mean follow-up time was 14 months. No recurrence was observed within this follow-up period.

The modified Bascom cleft lift technique is effective and reliable. It is applicable to all pilonidal sinus cases and has low complication rates, high satisfaction scores, rapid early recovery and low recurrence rates.

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Preoperative chemoradiation (CRT) for rectal cancer decreases the number of evaluable lymph nodes (NELN) found in the rescted specimen. However, the prognostic role of lymph node evaluation including overall numbers and the lymph node ratio (LNR) in patients having preoperative CRT are not yet defined. The study has assessed the influence of CRT on the NELN and on lymph node number and LNR on the survival of patients with rectal cancer.

Between 2003 and 2011, 508 patients with non-metastatic rectal cancer underwent mesorectal excision. Of these 123 (24.2%) received preoperative CRT. Univariate and multivariate analysis was performed to define the role of NELN and LNR as prognostic indicators of survival.

Neoadjuvant CRT significantly reduced the NELN (p<0.0001). Disease free survival (DFS) and overall survival (OS) of patients with less or more than 12 nodes retrieved did not differ statistically. Node negative patients with six or less lymph nodes were significantly associated with a poor DFS and OS on univariate analysis (p=0.03 and p=0.03). LNR significantly influenced the DFS and OS on multivariate analysis (DFS: p=0.0473, [hazard ratio (HR) 2.4980, 95% confidence interval (CI) 1.2631 - 9.4097], OS: p=0.0419 [HR 1.1820, 95% CI=1.1812 - 10,710]).

The cut-off of 12 lymph nodes does not influence survival and should not be considered for cancer specific prediction of patients having neoadjuvant CRT. In contrast LNR is an independent prognostic predictor of DFS and OS in such patients.

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The TMN staging system is the most important tool to predict long-term survival of colorectal cancer patients. However, physiological conditions and the operation may also influence survival. This study evaluated the impact of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and the colorectal version (CR-POSSUM) on the long-term survival of patients with rectal cancer.

Prospectively collected data were included of consecutive patients who underwent rectal cancer resection during 2000 – 2004. The relationship between the POSSUM and CR-POSSUM scores and the physiological components with outcomes and survivals were analyzed.

The study included 343 patients (196 males, 263 open resections, 74 laparoscopic resections, 6 local resections) with a mean follow-up of 56.5 months. Thirty-five patients had had neoadjuvant chemoradiation and 115 had adjuvant chemotherapy. Their median POSSUM score was 34 (interquartile range 31 - 39) and the median CR-POSSUM score was 19 (interquartile range 18 - 21). The Log rank test showed a significant difference (p<0.05) in long-term survival for patients who belonged to different score groups of POSSUM and physiological component of the POSSUM system. Factors found on multivariate analysis to have significant association with long-term survival included TMN stage, perineural invasion, local invasion, obstruction, emergency operation, POSSUM score and physiological score of POSSUM.

The mortality of patients after rectal cancer surgery can be predicted by POSSUM, P-POSSUM or CR-POSSUM with no significant difference between them. Both POSSUM and physiological score of POSSUM were significantly related with survival. The POSSUM score was one of the factors that independently predicted long-term survival.

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We report on our experience of elective subtotal colectomy and ileosigmoid anastomosis for colon cancer with focus on postoperative results, function and quality of life.

Between 1998 and 2011, 106 consecutive patients with colonic malignancy underwent this procedure electively. Function and quality of life (EORTC QLQ-C30) were evaluated retrospectively with questionnaires sent to all patients free of recurrence.

There were 62 males and 44 females (mean age 63 years). Postoperative mortality and morbidity rates were 1.9% and 26.4%. Persistent ileus was the main early complication (16%). After a mean follow-up of 67 ± 36 months, 50 (78.1) out of 64 patients have been evaluated for function and quality of life. The mean number of bowel movements per 24 hours was 3 ± 2 and significantly lower when the length of the remaining sigmoid colon was more than 15 cm (p=0.049). Compared with a European reference population for EORTC QLQ-C30 results, our patients had significantly more diarrhoea (26 vs. 3, p=0.0002), but less pain (10 vs. 25, p<0.0001) and better global quality of life (77 vs. 62, p<0.0001).

Elective subtotal colectomy for colon cancer is safe and associated with good function and quality of life. Ileosigmoid anastomosis should be discussed when extended colectomy is required, providing the rectosigmoid junction and its vascular supply can be oncologically preserved. For tumours located in the transverse colon or at the splenic flexure, this procedure may be the best surgical option.

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Passive post-defecatory incontinence is poorly understood and yet is an important clinical problem. The aim of this study was to characterize the pathophysiology of post-defecatory incontinence in patients affected by faecal soiling.

Seventy-two patients [30 women; age range, 49–79 years; 42 men; age range, 53-75 years] affected by faecal passive incontinence with faecal soiling were included in the study. Two patient groups were identified: Group 1 comprised 42 patients with post-defecatory incontinence and Group 2 had 30 patients without incontinence after bowel movements. After a preliminary clinical evaluation, including the Faecal Incontinence Severity Index (FISI) score and the Obstructed Defecation Syndrome (ODS) score, all patients of Groups 1 and 2 were studied by means of endoanal ultrasound (EU) and anorectal manometry (AM). The results were compared with those from 20 healthy control subjects.

A significantly higher ODS score was found in Group 1 (P < 0.001). EU revealed a significantly diffuse thinning of the internal anal sphincter (IAS) in Group 2 (P < 0.02) with a linear relationship between signs of internal anal sphincter (IAS) atrophy and the FISI score (p_s: 0.78; p< 0.03). Anal resting pressure (P_max and P_m) was significantly lower in Group 2 (p < 0.04). The straining test was considered positive in 30 (71.4%) patients in Group 1 significantly greater compared with Group 2 (p < 0.01). A significantly higher conscious rectal sensitivity threshold (CRST) was found in Group 1 patients (p < 0.01).

The ODS score, a positive straining test, and high CRST values suggest that post-defaecatory incontinence is secondary to impaired daefecation.

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The annual incidence of colonic diverticular bleeding is increasing, but treatments are not yet well established. Here we aimed to identify the risk factors for early re-bleeding and to determine the associated duration of hospitalisation.

Records of 90 emergent patients with colonic diverticular bleeding between 1999 and May 2012 were retrospectively reviewed. They were divided into an early re-bleeding within 1 month (n = 24) and a no re-bleeding group (n = 66) and investigated the risk factors for early re-bleeding. In the former, we calculated the time from the first haemostasis to early re-bleeding and the associated duration of hospitalisation.

Univariate analysis showed that there were significantly more patients with signs of shock (P = 0.00055) and active bleeding on the first colonoscopy after admission (P = 0.020) in the early re-bleeding group. Multivariate conditional logistic regression analysis using stepwise variable selection showed signs of shock on admission (odds ratio, 5.23; 95% confidence interval, 1.84–14.90; P = 0.0019) remained statistically significant. All patients who re-bled without signs of shock (n = 7) and 16 of 17 with signs of shock re-bled within 126 h (5.25 days) of initial hospitalisation.

Shock was an independent risk factor for early re-bleeding. The associated duration of hospitalisation was 6 days.

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The benefits of a laparoscopic approach to restorative proctocolectomy (RPC) are controversial. The aim of this meta-analysis was to compare the outcome following laparoscopic and open RPC, with particular attention to adverse events and long-term function.

A systematic search of the MEDLINE, EMBASE and Ovid databases was performed for studies published until March 2012. The primary endpoint was long-term function. Secondary endpoints were intra-operative details and short-term post-operative outcome and post-operative adverse events. Weighted mean difference (WMD) and odds ratio (OR) were calculated using fixed/random effect meta-analytic techniques.

The final analysis included 27 comparative studies of 2428 patients, of whom 1097 (45.1%) underwent laparoscopic surgery. A laparoscopic approach was associated with a significantly longer operation time (WMD 70.1 minutes, p<0.001), shorter length of hospital stay (WMD -1.00 day, p<0.001), reduced intra-operative blood loss (WMD -89.10 millilitres, p<0.001) and a lower incidence of wound infection (OR 0.60, p<0.005). No significant differences were observed in the rate of pouch failure. Although there was no significant difference in the number of daily bowel movements (OR 0.04, p=0.950), laparoscopic surgery led to fewer nocturnal bowel movements (WMD -1.14, p<0.001), and reduced pad usage during the day (OR 0.22, p<0.001) and night (OR 0.33, p<0.001). The post-hoc power to detect differences in adverse event rates ranged from 5% to 42%.

Laparoscopic and open approaches to RPC produced equivalent adverse events rates and long-term functional results. However, the present evidence is underpowered to detect true differences in adverse event rates.

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The aims of this systematic review were to determine the presentations of diverticular disease in patients under 40 years and to assess whether obesity is an important factor.

The PubMed and EMBASE databases and the Cochrane Library were searched to identify all original articles published between 1990 and 2011 on diverticular disease severity in obese patients (BMI of ≥30kg/m²) under 40 years.

Twenty three clinical case series (two of which were prospective) were identified plus two large aetiological population-based studies. These reported that young patients with diverticular disease were presenting more frequently and that diverticular disease in this age group was less likely to be complicated but emergency operation rates were higher. The majority (63.1% - 96.5%) of patients under 40 years with diverticular disease were obese.

The studies suggest that in the young, obese patient with lower abdominal pain, diverticulitis and appendicitis are included in the differential diagnosis. Computerised tomography (CT) and/or laparoscopy should be considered where the diagnosis is in doubt.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The study compared the postoperative Health related Quality of Life (HQoL) of patients undergoing elective open colorectal surgery using a well established enhanced recovery after surgery (ERAS) pathway to those undergoing laparoscopic surgery without an established an ERAS pathway.

Using a power calculation, it was estimated that 40 patients would be required in each group. Health related quality of life (HQoL) of the two groups was prospectively assessed using SF 12 (short form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at two and six weeks after discharge.

Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open-ERAS group. There was a significant difference between the median length of stay of the open-ERAS (5 days) and laparoscopic group (7 days, p=0.028). There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL score had improved considerably by 6 weeks.

Laparoscopic and open-ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6 week stage.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

For any surgical treatment of full thickness rectal prolapse little attention has been given to quality of life (QoL). This study prospectively evaluated continence, constipation and QoL after perineal rectosigmoidectomy for full-thickness rectal prolapse in young and elderly patients in the long term.

From May 2003 to May 2010, consecutive patients suffering from full-thickness rectal prolapse undergoing perineal rectosigmoidectomy were prospectively studied. A standardised questionnaire including the Cleveland Clinic Constipation and Incontinence Scores (CCCS and CCIS), and generic and constipation-specific QoL scores (EQ-5D and PAC-QOL), was administered pre- and postoperatively. The Wilcoxon test (EQ-5D) and two-sample Student's t-test (EQ-VAS, CCCS, CCIS and PAC-QOL) were used for statistical analysis.

53 patients (47 female) aged 72.7 (range 30-89) years underwent perineal rectosigmoidectomy. One patient died and one patient needed reoperation. Five full-thickness recurrences occurred. Thirty seven patients completed the follow-up questionnaire at a median of 49 (6-89) months. Postoperative incontinence and constipation improved significantly (CCIS from 13±7.28 to 8.7±6.96 and CCCS from 8.32±6.96 to 3.49±4.17). Furthermore, QoL in terms of mobility, usual activity, pain/discomfort and anxiety/depression and subjective state of health, were significantly better at follow-up (P<0.001). All dimensions of constipation-related QoL improved (P<0.001). Results did not differ between patients under or over 69 years.

Patients experience improved general and constipation-related QoL after perineal rectosigmoidectomy independent of age.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

To determine the relationship between obstructed defecation syndrome (ODS) and rectoceles.

From 12/07 to 11/11, all female patients with ODS were prospectively evaluated with full interview, clinical exam and anorectal physiology testing. Characteristics of patients with and without rectoceles were compared, and logistic regression was utilized to identify factors predictive of patients having a rectocele beyond the introitus.

Of 239 patients with ODS, 90 (mean age 52.3±1.7 years) had a rectocele. Patients with rectoceles (R+) had a similar prevalence of incomplete emptying compared to patients with no rectocele (R-) (p≥0.21), but only R+ patients reported splinting with defecation (36.7% vs. 0%; p<0.0001). Anorectal manometry measurements including mean resting pressure, maximum resting pressure, and maximum squeeze pressure were similar between groups (p≥0.12). There were also no significant differences in rectal compliance (maximum tolerated volume) or rectal sensitivity (volume of first sensation) (p≥0.65). R+ patients had greater difficulty expelling a 60cc balloon (70.1% vs. 57.5%; p=0.05), but prevalence of pelvic floor dyssynergia as quantified by non-relaxation on EMG testing was similar to R- patients (p=0.49). Logistic regression suggested that only difficulty with balloon expulsion was associated with higher odds of having a rectocele (OR 3.00; p=0.002), whereas mean resting pressure, EMG non-relaxation, and symptoms of incomplete emptying were not (p≥0.12).

Rectoceles are not associated with an increased severity of ODS-type symptoms, anorectal abnormalities, or pelvic floor dyssynergia in patients with ODS. This suggests that rectoceles may be the result, rather than the cause, of obstructed defecation syndrome.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

‘Predict, resect, and discard’ strategies for diminutive and small colonic polyps are considered to be cost effective for treating colorectal cancers. The aim of this study was to retrospectively determine the histological features of colonic polyps resected by endoscopic procedures or surgery using an updated database.

We retrospectively analysed the clinicopathological features of colorectal polyps, less than 20 mm in size, which were removed by endoscopy from January 2009 to November 2011 at the National Cancer Center Hospital (NCCH), Tokyo, Japan.

Less than 1% diminutive polyps (≤5 mm) were classified as mucosal high-grade neoplasia (Category 4), and no submucosal invasion by carcinoma (Category 5) lesions were noted. However, 3% of small polyps (6–9 mm) were classified as Category 5; of these, 6% were submucosal deep invasive cancers. Morphologically, depressed components were observed more frequently in carcinomas than in adenomas in both small and large polyps (10–20 mm).

In light of the ‘predict, resect, and discard’ strategies for small polyps, we should pay attention to the possible clinical malignancy of small and large polyps. We recommend that these strategies be applied selectively and that they be informed by accurate endoscopic evaluations.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors’ preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intraoperative and short-term outcomes.

Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intraoperative and short-term outcomes were evaluated.

The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and 9 had a coloanal pull-through procedure (mean age 60.1 years; mean BMI 28.0; mean operative time 327 minutes; conversion rate 3.9%). Three patients (3.9%) had positive resection margins

(1 circumferential 2 distal). Five patients had an anastomotic leak (6.4%). No robotspecific complications were observed.

The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The purpose of this study was to examine factors related to treatment failure following chemoradiation for squamous cancer and to compare the outcome of salvage surgery in one unit with national audit standards published by the Association of Coloproctology of Great Britain and Ireland (ACPGBI<comment></comment>)[1] ..

Patients with squamous cell carcinoma of the anus treated with radical intent between1997 and 2010 in a single tertiary referral oncology institute were prospectively identified. Multivariate analysis was used to establish factors associated with treatment failure. Cancer specific end points after salvage surgery were determined by Kaplan Meier survival analysis.

95 patients received chemoradiation with radical intent with a 5 year overall survival of 83% (all stages) at a median follow up of 35 months. Of these, 11(12%) required salvage surgery, five whom were stage T4 at presentation. Six patients had failed to respond to chemoradiation and five presented with recurrence at a median of 10 (10-36) months. Only stage T4 disease at presentation was predictive of the need for salvage surgery (OR 5.6, CI 4.9-6.3, p=0.015). There was no surgical mortality and no delayed perineal healing where a myocutaneous flap was used. The resection margin was involved on one (9%) patient. The five year survival rate was 64%. Audit standards for case selection, local control, survival and perineal complications were achieved.

Long term survival was achieved in two thirds of patients following salvage surgery after failed primary chemoradiotherapy for anal cancer in a multidisciplinary oncological unit. Stage T4 disease at presentation strongly predicted the need for subsequent salvage intervention.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Laparoscopic ventral mesh rectopexy (VMR) is a surgical treatment option for internal and external rectal prolapse with low perioperative morbidity and low recurrence rates. Synthetic mesh use in the pelvis may be associated with complications such as fistulation, erosion and dyspareunia. Biologic meshes may avoid these complications, but the long-term outcome is uncertain. Debate continues as to which type of mesh is optimal for laparoscopic VMR.

A literature search was performed of electronic databases including Medline, Embase and Scopus (2000-2012). Studies describing outcomes relating to the mesh were included for review. Only English language studies were included.

Thirteen observational studies reported the outcome of 866 patients following laparoscopic VMR. Eleven studies reported the outcome using synthetic mesh with a median follow up ranging from 7-74 months. Two studies reported the outcome with biologic mesh with a median follow up of 12 months. Pooled analysis of the studies demonstrated that 767 patients had a repair with synthetic mesh and 99 with a biological implant. There was no difference in recurrence (3.7% v 4.0%, p = 0.78) or mesh complications (0.7% v 0%, p = 1.0%) between synthetic and biologic mesh repair.

Biologic meshes appear to be as effective as synthetic meshes in the short term for laparoscopic VMR. Mesh complication rates are low in both groups. Long-term follow up is required to ascertain if these findings persist.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Diaphragmatic disease is rare. This review aims to increase awareness of this condition and its management.

A literature search was conducted using the key terms ‘colon’ or ‘colonic’ in combination with ‘diaphragm’ or ‘diaphragm disease’ for publications until August 2012. All cases of colonic diaphragm syndrome were identified and to the required data was collected.

Forty five cases of colon diaphragm disease were included. The highest incidence was in the 7^th decade of life, with a female preponderance (40F:5M). Most patients presented with chronic (median 3 months) and multiple symptoms. The median usage of NSAID was 5 years including Diclofenac as the most commonly used NSAID. Colonoscopy was the most informative investigation and the ascending colon was the most common site of diaphragm disease. Nearly two thirds of the patients were treated by discontinuing NSAID treatment combined with other forms of treatment, mostly surgery.

Diaphragm disease of the colon is a rare condition associated with long term use of NSAID with a range of presentations and symptoms. Based on this review, when colon diaphragm disease is diagnosed we would recommend a trial cessation of NSAID. Therapeutic endoscopic techniques should be considered but surgery may be required for definitive treatment

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

XELOX and FOLFOX4 have both been recommended as adjuvant therapy for stage III colon cancer. This study compared the two regimens in terms of monetary costs, assuming equal efficacy of both regimens.

A retrospective financial audit was conducted of the medical records of patients treated with XELOX or FOLFOX4. All itemized expenses were classified as direct (chemotherapy, hospitalization, venous access, and tests), related to adverse effects due to the adjuvant therapy, or societal (travel and time costs). The cost of supportive care was not included.

XELOX involved less total cost to the patient than FOLFOX4 (a difference of US$2857.68), less costs related to the adverse effects ($668.97), and less travel ($26.07) and time ($390.93) expenditure per patient.

The results indicate that XELOX is, overall, a more affordable option than FOLFOX4 in China.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Anal fissures can be resistant to treatment and some patients may undergo several trials of medical therapy before definitive surgery.. It would be useful to identify predictors of poor response to medical therapy.. This study assesses the role of anorectal physiological criteria to identify patients with anal fissure predicted to fail Botulinum toxin (BT) treatment

A retrospective analysis of anorectal physiological data collected for patients with resistant chronic anal fissures referred to one consultant surgeon between 2007-2011 was undertaken. These were correlated with treatment plans and healing rates.

Twenty-five patients with idiopathic chronic anal fissures underwent anorectal physiology studies and were subsequently treated with BT injection. Eleven had a characteristic high-frequency low-amplitude ‘saw tooth’ waveform or Anal Sphincter Fibrillation (ASF) and higher anal sphincter pressures. Nine of these patients (82%) had resolution of their anal fissure symptoms following treatment with BT. Of 14 patients with no evidence of ASF and a greater range of anal sphincter pressures, only 1 (7%) had resolution following BT..

ASF appears to be an anorectal physiological criterion that helps predict response of anal fissures to BT injection. This could help streamline fissure management.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Annexin A2 (ANXA2) is known to be a tumorigenic molecule and is highly expressed in colorectal cancer (CRC). Its diagnostic and prognostic value is not fully understood. This study was designed to investigate the relationship between ANXA2 expression, clinicopathological characteristics, tumour recurrence, and survival.

Immunohistochemical staining was used to evaluate ANXA2 expression in 150 matched samples from patients with colorectal cancer (CRC). Overall survival and recurrence were determined by Kaplan-Meier analysis. The Cox proportional hazards model was used to determine independent factors contributing to survival and recurrence. Receiver operating characteristic (ROC) curve and liner correlation analysis was used to estimate the sensitivity and specificity of ANXA2 expression for clinical diagnosis.

ANXA2 was found to be strongly expressed in poorly differentiated tumours (p < 0.001), late stage (p = 0.020) and lymph node positivity (p = 0.002). ANXA2 expression was significantly related to recurrence (p < 0.001) and survival (p = 0.002). Cox proportional hazards model indicated that ANXA2 expression (p < 0.001, HR=1.366, 95%CI 1.232-1.515) and tumour location (p = 0.039, HR=1.891, 95%CI 1.034-3.456) were independent factors in predicting overall survival while ANXA2 expression (p < 0.001, HR=1.445, 95%CI 1.222-1.709) were independent factors predicting recurrence. Receiver operating characteristic (ROC) (AUC=0.768, 95%CI=0.642-0.894) and liner correlation analysis suggested ANXA2 was suitable for the clinical diagnosis of CRC.

These results indicate that ANXA2 is a biomarker with diagnostic and prognostic potential for patients with CRC.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Since 2005, we have used SEMS as primary treatment for all patients with left-sided obstructing colorectal cancer without evidence of perforation. The purpose of this study was to assess the safety and efficacy of this treatment.

This was a prospective study of consecutive patients with left sided obstructing colorectal cancer without perforation or peritonitis treated between January 2005 and June 2009. SEMS placement was attempted in all cases. Emergency surgery was reserved for patients in whom a stent placement failed. After successful decompression, surgery was offered to patients with potentially curable disease.

Seventy-seven patients were included, with successful SEMS placement in 60/77 (78%) patients, 25 as a bridge to surgery and 35 for palliation. Immediate complications occurred in two (3%) cases. There was no mortality. Of 35 patients in whom SEMS was for palliation, 32(91%) avoided surgery altogether. A stoma was fashioned in 5 (8.3%) of the 60 patients who were successfully stented, and in 12 (71%) of the 17 patients in whom stenting failed (p=0.0001).

A SEMS- based management protocol for patients with large bowel obstruction due to colorectal cancer is safe and effective.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Doppler guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy.

This review was conducted in keeping with PRISMA guidelines. MEDLINE, EMBASE, Google Scholar and Cochrane Library databases were searched. Studies describing DGHL as a primary procedure and reporting clinical outcome were considered. Primary endpoints were recurrence and post-operative pain. Secondary endpoints included operation time, complications and reintervention rates. Studies were scored for quality with either Jadad score or NICE scoring guidelines.

28 studies including 2904 patients were included in the final analysis, . They were of poor overall quality. Recurrence ranged between 3 – 60% (pooled recurrence rate 17.5%), with the highest rates for grade IV haemorrhoids. Post-operative analgesia was required in 0-38% patients. Overall post-operative complication rates were low, with an overall bleeding rate 5% and an overall reintervention rate of 6.4%. The operation time ranged from 19-35 minutes.

DGHL is safe and efficacious with a low level of post-operative pain. It can be safely considered for primary treatment of grade II and III haemorrhoids.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Successful anal fistula care is aided by specialized imaging accurately defining the site of the internal opening and fistula type. Imaging techniques are complementary, designed to answer specific anatomical questions. There are limited data concerning the clinical value of transperineal ultrasound (TP-US) in both cryptogenic fistula-in-ano and perianal Crohn's disease (PACD). The aim of the study was to assess the accuracy of TP-US when compared with operative findings in patients with perirectal sepsis.

Patients with recurrent cryptogenic anal fistula and PACD referred for sonography were examined using TP-US by a single examiner blinded to the operative results. Fistulae were categorized by the Parks’ classification predicting the site of the internal fistula opening. Ancillary horseshoe collections, abscesses and secondary tracks were defined.

Fourteen patients with PACD and 27 patients with recurrent cryptogenic fistula-in-ano were analyzed with comparative images and operative data. Correlation of fistula type for cryptogenic and PACD patients respectively was 23/27 (85.2%) and 12/14 (85.7%), with a correlative internal opening site (when found at surgery) of 16/22 (72.3%) and 12/14 (85.7%). Misclassification of fistula type in cryptogenic cases occurred in the presence of ancillary abscesses with associated acoustic shadowing. In PACD patients, TP-US was used when anal stenosis precluded endoanal ultrasonography, assisting in the diagnosis of rectovaginal fistulae.

Transperineal ultrasound is a useful complementary technique to assess fistula-in-ano and has special advantage when there is anal canal distortion, complex fistula type or suspicion of a rectovaginal fistula.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of GreatBritain and Ireland

Questionnaires were sent to 768 clinicians (doctors and nurses) working in colorectal cancer, identified from professional databases. These data were complemented by in-depth interviews exploring opportunities and barriers to giving lifestyle advice.

A total of 323 replies were received (42% response rate) and twenty respondents completed in-depth interviews. Half (52%) reported they were familiar with guidance for lifestyle advice for cancer survivors. Most (77%) thought reducing weight was important for improving the health of those who were overweight and 75% thought it appropriate to offer lifestyle advice to people with body mass index (BMI) over 30kg/m2. Half (50%) reported that weight reduction was an important service priority for normal clinical practice Half (50%) of respondents said that they would value additional training in this area. Interview data revealed that current practice is influenced by the lack of evidence for the impact of weight management, and a belief that “weight gain is good and weight loss bad” in the cancer setting. Patient sensitivity, time available, role constraints and lack of skills in weight management were also factors.

There is an awareness of the importance of weight management amongst colorectal clinicians and some indication of advice being provided. However, current perceptions, knowledge and skills suggest scope for further training.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Enhanced Recovery After Surgery (ERAS) program is a multimodal approach to improve perioperative care in colon surgery. The aim of this study was to report on the adherence to and outcomes of ERAS in the first years after implementation.

Data of patients undergoing elective colon resections for malignancy in 2006 till 2010 were compared with patients receiving conventional care in 2005. Retrospective analysis was performed including length of stay (LOS), protocol adherence and complications. The predictive value of ERAS items and baseline characteristics on LOS and complications were analyzed using univariate and multivariate analysis.

LOS was significantly shorter in 2006 and 2007 (p ≤ 0.009 and p ≤ 0.004), but not in 2008 and 2009. The mean adherence rate to the ERAS items was 84.1 % in 2006 and 2007, and 72.4 % in 2008 and 2009 (p< 0.001). In 2005, 2008 and 2009 LOS was significantly shorter for laparoscopically operated patients than for patients with open resections (p<0.002, p<0.001 and p< 0.004, resp.). Multivariate analysis showed that age, laparoscopic surgery, removal of nasogastric tube before extubation, mobilization within 24 hours after surgery, starting NSAIDs at day 1 and removal of thoracic epidural analgesia at day 2 were independent predictors of LOS.

Strict adherence to the ERAS protocol was associated with reduced LOS and improved outcome in elective colon surgery for malignancy. These benefits were lost when protocol adherence was lower. Embedding the ERAS protocol into an organisation and repetitive education are vital to sustain its beneficial effects on LOS and outcome.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

A systematic review was performed to assess whether education of patients having stoma formation improves quality of life and whether it is cost effective.

A literature search was performed to identify studies on the structured education of ostomates and outcome using the following databases: MEDLINE, Cinahl, Embase, Cochrane and PsycInfo. Inclusion criteria were: clinical studies reporting effects of educational interventions in relation to patients with a stoma. Commentaries or studies not testing an intervention were excluded.

Seven articles met the inclusion criteria of having rigorously evaluated an educational programme related to living with a stoma. The programmes were organized in different ways and had explored varous interventions. The results showed an increase in health-related quality of life measured with a Stoma QOL in strument (p=0.00001) and with SF-36 (p=0.000-0.006), an increase in proficiency in management of the stoma (p=0.0005), two studies pointed to a reduction in post-operative hospital stay (8 vs 10 days, p=0.029), and (8 vs 14 days, p = 0 .17), a significant reduction in cost in the intervention group (8570.54 USD) compared with the control group (7396,90 USD) as well as higher effectiveness scores in the intervention (166,89) compared with the control group (110.98). a significant rise in stoma-related knowledge (p=0.0000), and an increase in psychosocial adjustment (p= 0.000).

Structured patient education aimed at patients’ psychosocial needs seems to have a positive effect on quality of life as well as cost. The interventions may be performed before, during or after hospital stay. However, the available data come from few studies with differences in interventions and study design, and further studies are therefore needed before a final conclusion can be drawn.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The impact of anorectal malformations (ARM) on bowel function and social, educational and occuptational end points was investigated in adult patients entered on a national database.

Data from a national database of adult patients operated between 1962 to 1999 for ARM were analyzed, The database Malformations Ano-rectales et Pelviennes rares (MAREP), was part of a common information system, CEMARA, on rare congenital disorders. A self-administered questionnaire regarding bowel function, academic qualifications, employment and family status, was mailed to patients. The type of ARM, subsequent follow-up and management including surgical interventions were retrospectively retrieved from medical records.

68 adult patients of 210 on the registry since 2008, were included in this study. Only three (8.5%) had had regular follow-up. All reported some disturbance in bowel function The fertility rate of 1.5 children per woman did not differ from the general population.

ARM often leads to suboptimal bowel function in adulthood. This has an impact on social integration.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Total mesorectal excision with preoperative radiotherapy reduces local recurrence in rectal cancer, but radiotherapy increases the risk of complications. The study compared the immediate postoperative outcome after external beam radiotherapy with high dose endorectal brachytherapy (HDREBT).

Patients (n=318) treated with preoperative HDREBT, (26 Gy over 4 days) followed by surgery after 4-8 weeks were matched with 318 patients from the Swedish Rectal Cancer Register treated with 5 Gy daily over 5 days and surgery in the subsequent week (SCRT) and 318 having surgery alone. All 954 patients were followed for 30 days after surgery. Complications were divided into surgical, cardiovascular and infectious.

The SCRT group had fewer cardiovascular complications (3.1%) than HDREBT (9.4%, p=0.002) and RT- (7.2%, p=0.03). Perioperative bleeding was less in HDREBT patients (379.3 ml) than SCRT (947.2 ml; p<0.0001) and RT- (918.9 ml), and the re-intervention rate was lower in HDREBT (4.1%) than SCRT patients (14.2%; p=0.005) and RT- (12.3%; p<0.005). The HDREBT group had fewer R2 resections than the SCRT and RT- groups, but a higher proportion of R0-resections than the RT- group (p=0.03).

No major differences in postoperative complications were found. HDREBT patients had a higher rate of cardiovascular complications but less perioperative bleeding and fewer re-interventions. A longer interval between radiotherapy and surgery may be beneficial for tumour regression and this could be reflected in the number of radical resections.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

There is recent interest in the measurement of peritoneal fluid cytokines in the early post operative period, to help diagnose anastomotic leakage at a preclinical stage. The currently available literature on the early diagnosis of colorectal anastomotic leakage by estimation of drain fluid cytokines or matrix metalloproteinases (MMP) is reviewed.

A literature search was performed in PubMed, Embase and the Cochrane library for all publications studying the feasibility to diagnose colorectal anastomotic leakage earlier, by estimation of peritoneal fluid cytokine or MMP levels. A meta-analysis of the most commonly measured cytokines was performed.

Eight publications were included. Tumour necrosis factor-α (TNF-α) and Interleukin-6 (IL-6) were most frequently studied. Most studies found significantly higher levels of TNF-α and IL-6 in patients with anastomotic leakage during the first three post-operative days. In the meta-analysis IL-6 levels were significantly higher from day 1 and TNF-α from day 2. MMP-9 was most often significantly elevated in patients with anastomotic leakage.

Measurement of drain fluid cytokines and MMP has the potential to diagnose colorectal anastomotic leakage at a pre-clinical stage, but is not yet ready for clinical use. Further research is needed, possibly using IL-6 in combination with other cytokines and MMP as markers.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly and parous women. There is no accepted standard surgical treatment, with previous studies limited in methodological quality and size. PROSPER aimed to address these deficiencies by comparing the relative merits of different procedures.

In a pragmatic, factorial (2x2) design trial, patients could be randomised between: abdominal and perineal surgery (a), and suture versus resection rectopexy for those receiving an abdominal procedure (b) or Altemeier's versus Delorme's for those receiving a perineal procedure (c). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores (Vaizey, bowel thermometer and EQ-5D) measured up to three years.

293 patients were recruited to 340 comparisons: 49 to the comparison between surgical approach (a), 78 to an abdominal procedure (b) and 213 to a perineal procedure (c). Recurrence rates were higher than anticipated, but not significantly different in any comparison: Altemeier's versus Delorme's 24/102 (24%) and 31/99 (31%) (HR 0.81, 95% CI: 0.47, 1.38; p=0.4); resection versus suture rectopexy 4/32 (13%) and 9/35 (26%) (HR: 0.45, 95% CI: 0.14, 1.46; p=0.2); abdominal versus perineal 5/19 (26%) and 5/25 (20%) (HR: 0.83, 95% CI: 0.24, 2.86; p=0.8). Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons.

No significant differences were seen in any of the randomised comparisons, although substantial improvements in quality of life were noted.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of GreatBritain and Ireland

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option with curative intent for selected patients with peritoneal carcinomatosis (PC). CRS and HIPEC were implemented in Denmark at a single centre since 2006. Six-year data of these patients were analyzed.

Patients with PC from colorectal or appendiceal cancer, pseudomyxoma peritonei, or malignant peritoneal mesothelioma referred to the single, national HIPEC centre were prospectively registered from June 2006 to July 2012. Morbidity, 30-day mortality and long-term survival of patients who underwent CRS and HIPEC were analyzed.

In total, 80 patients underwent CRS and HIPEC. PC originated from CRC in 34 patients, PMP in 29, appendiceal cancer in 13, and malignant peritoneal mesothelioma in 4 patients. Thirty-two patients had one or more complications during the hospital stay. The 30-day mortality rate was 1.3%. The predicted 2-year, 3-year, and 5-year survival was 60%, 47% and 38% in patients with PC from CRC, and 100%, 93% and 73% in PMP patients.

CRS and HIPEC is a safe procedure when centralised as in Denmark. Favourable long-term outcome was achieved in selected patients with PC from CRC and PMP. Short-term and long-term outcome were comparable to results from international centres.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Most consultants participating as referees in the peer review process of articles submitted to scholary journals have had no training or tuition. This study attempted to evaluate the effect on reviewing of a half-day course held at the Royal Society of Medicine (RSM)

Registered consultant delegates were sent two “doctored” papers, a case report and an original article, well before the meeting to review at home using the standard computerised score sheet issued with referee requests by Colorectal Disease. At the start of the actual meeting the scores were entered into a computer as “Before”. After each paper had been presented and then discussed, it was re-marked to give the “After” score. The “Before & After” scores were compared with the post-meeting feedback forms.

The Before and After scores were not significantly different for papers which were rejected for publication. For other papers the Before score was higher than the After score for Abstract, Materials and Methods, Results and Discussion. Feedback forms from the meeting were all positive.

Consultants have the expertise to decide whether a paper should be rejected. The study day appears to give an additional insight which may change an initial opinion. In general a paper scored before the meeting was scored lower after it was presented and discussed. at the meeting. (the tuition).

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Many women undergoing sacral neuromodulation for faecal incontinence have coexisting pelvic floor dysfunction. We used a global pelvic floor assessment questionnaire to evaluate the effect on non-bowel related symptomatology.

The ePAQ-PF is a validated web-based electronic pelvic floor questionnaire. Women with faecal incontinence underwent assessment using ePAQ. Pre and post stimulator data were analysed over a 4.5-year period.

43 women were included (mean age 56.5 years, median follow up 6.8 months). 100% had urinary symptoms, 81.4% had vaginal symptoms and 85.7% described some sexual dysfunction. There was a significant improvement in faecal incontinence and bowel related quality of life (p<0.005) as well as IBS related symptoms (p<0.01) and bowel related sexual heath (p<0.01). Symptoms of vaginal prolapse significantly improved (p=0.05). There was also improvement founding symptoms of overactive bladder (p=0.005) and urinary-related quality of life (p<0.05). A global health improvement was reported in 58.1% mainly in bowel evacuation (p<0.01) and vaginal pain and sensation (p<0.05). In sexually active females, significant improvements in vaginal and bowel related sexual health were seen (p<0.005). Improvement in general sex life following stimulation was reported in 53.3%.

A web-based electronic pelvic floor assessment questionnaire (ePAQ) has demonstrated global improvement in pelvic floor function in bowel, urinary, vaginal and sexual dimensions in women following sacral neuromodulation for faecal incontinence.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

There is evidence that preoperative carbohydrate drinks and postoperative nutritional supplements toghether improve the outcome of colorectal surgery. There is little information on their individual contribution.

A prospective four-arm double blind controled trial was varied out in which patients were randomised to carbohydrate or placebo drinks preoperatively or a polymeric supplement or placebo drink postoperatively. The primary outcome was insulin resistance (using the short insulin tolerance test and HOMA IR). Secondary outcomes included handgrip strength, pulmonary function, intestinal permeability and postoperative complications.

120 patients were randomised to four demographically well matched groups. Patients who received pre and postoperative supplements had better glucose homeostasis (p=0.004), PEFR (p=0.035), handgrip strength (p=0.002) and less insulin resistance (p=0.001) compared with those who only received placebo drinks.

Oral nutritional supplements given pre and postoperation improve post-operative handgrip strength, pulmonary function and insulin resistance. A weaker effect was seen in patients who received supplements either pre or postoperatively. Oral nutritional supplements should be given both pre and postoperatively.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

This retrospective study aimed to determine functional results of Laparoscopic Ventral Rectopexy (LVR) for rectal prolapse (RP) and symptomatic rectoceles in a large cohort of patients.

All patients treated between 2004 and 2011 were identified. Relevant patient characteristics were gathered. A questionnaire concerning disease related symptoms as well as the Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) was sent to all patients.

A total 245 patients were operated. Twelve patients (5%) deceased during follow-up (FU) and were excluded. Remaining patients (224 females, 9 males) were sent a questionnaire. Indications for LVR were: external RP (n=36), internal RP or symptomatic rectocele (n=157) or a combination of symptomatic rectocele and enterocele (n=40). Mean age and follow-up were 62 years (range: 22-89) and 30 months (range 5-83), respectively. Response rate was 64% (150 patients). The complication rate was 4.6% (11 complications). A significant reduction in symptoms of constipation or obstructed defecation syndrome (ODS) was reported (53% of patients before vs. 19% after surgery, P< 0.001). Mean CCCS during FU was 8.1 points (range 0-23, SD ± 4.3). Incontinence was reported in 138 patients (59%) before surgery and in 32 patients after surgery (14%), indicating a significant reduction (P<0.001). Mean CCIS was 6.7 (range 0-19, SD ± 5.2) after surgery.

A significant reduction of incontinence and constipation or ODS after LVR was observed in this large retrospective study. LVR therefore appears a suitable treatment for RP and rectocele with and without associated enterocele.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The long-term effects of surgical and non-surgical factors on increased stool frequency and incontinence following anterior resection have been variably reported. We investigated the effects of surgical characteristics on symptoms at one month and more than one year postoperatively following anterior resection of the rectum.

In this retrospective study of patients who underwent anterior resection of the rectum during 2002-2006, patients were interviewed regarding symptoms at one month and more than one year postoperatively. Anterior Resection of the Rectum Syndrome (ARRS) was more simply defined as incontinence and/or frequent bowel movements after surgery and graded as severe, moderate, or mild.

Of the 165 patients who underwent anterior resection for rectal cancer during the study period, 106 were included in the analysis. The median follow-up period was 3.4 years (range 13-72 months). ARRS had as high prevalence one month postoperatively (55.6%) but abated in over half the cases at one year postoperatively. The likelihood of development of early but not late ARRS was associated with the anastomotic level suggesting adaptation. ARRS and continence were unaffected by total mesorectal excision, the use of adjuvant radiation or chemotherapy, patient age or disease stage.

The level of anastomosis in anterior resection of the rectum had a significant effect on the prevalence of ARRS using a new simpler definition one month after surgery but not more than one year postoperatively. Further data on neorectal reservoir reconstruction using the simpler ARRS definition are required.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Restorative surgery after (procto)colectomy with ileo neo rectal anastomosis (INRA) or restorative proctocolectomy with ileal pouch anal anastomosis (RPC) combines cure of ulcerative colitis (UC) with restoration of intestinal continuity. This study aimed to evaluate these two operations.

Patients having INRA and RPC were matched according to sex, age at onset of UC, age at restorative surgery, and duration of follow-up. Patients were included if they were over 18 years of age, had UC confirmed histopathologically, and had undergone either operation. Long-term function, anal and neorectal physiology, complications, quality of life (QoL), and health status (HS) were determined.

Seventy-one consecutive patients underwent surgery with the intention of performing an INRA procedure. This was successfully carried out in 50, 21 underwent intraoperative conversion to RPC. Median defaecation frequency was 6/24 hours. In 11/71 patients reservoir failure occurred and 13/71 developed pouchitis. QoL and HS was comparable to the healthy population. Median follow-up was 6.2 years.

These patients were matched with 71 patients who underwent restorative proctocolectomy. RPC was successful in all patients. Median defaecation frequency was 8/24 hours. Failure occurred In 7/71 patients and 13/71 developed pouchitis. QoL and HS were comparable with the healthy population. Median follow-up was 6.9 years.

Comparison of INRA and RPC on an intention to treat basis was not considered to be realistic due to the high intraoperative conversion rate and the failures in the INRA group. RPC remains the procedure of choice for restoring intestinal continuity after proctocolectomy for ulcerative colitis.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

A tension-free anastomosis is required to minimize anastomotic leakage after an extended left colectomy when the residual transverse colon is too short to spontaneously reach the pelvis. To resolve this problem, colonic rotation with a right colonic transposition (RCT) or even with a complete intestinal derotation (CID) is mandatory. This study compared these two techniques.

Between January 2001 and December 2011, 39 patients had undergone RCT (n=29) or CID (n=10) after an extended left colectomy. All anastomotic complications had been recorded during the follow-up.

No differences were found between RCT and CID in terms of patient characteristics, surgical indications, therapeutic features and risks factors for anastomotic leakage (sex, ASA score, diabetes, bevacizumab use, colorectal anastomotic level, protective stoma use). Ligature of the middle colic artery was significantly more frequent with RCT than with CID (82.7% vs 50%, p=0.04). An additional colonic resection tended to be required more often in the RCT group than in the CID group (55.1% vs 20%, p=0.054). The anastomotic complication rate was 10.2% and was not different between RCT and CID (6.9% vs 20%, p=0.24).

Both colonic rotation techniques are feasible and safe. The RCT and CID techniques yielded similar results in terms of colorectal anastomotic complications but RCT had required ligature of the middle colic artery and additional colonic resection tended to be required more frequently.

This is the first series to assess the results of complete intestinal derotation

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The study aimed to determine whether non-alcoholic fatty liver disease (NAFLD) is an independent risk factor of adenoma after negative baseline colonoscopy.

A retrospective cohort study was conducted on 1522 health-check individuals who underwent two consecutive colonoscopies at Taipei Veterans General Hospital between 2003 and 2010. Those developing an adenoma after an initial negative baseline colonoscopy (Adenoma Group) were compared with those in whom the second colonoscopy was negative (Non-adenoma Group). Anthropometric measurements, biochemical tests, and the presence of NAFLD were compared between the two groups.

The Adenoma Group had a higher prevalence of NAFLD than the Non-adenoma Group (55.6% vs. 38.8%, p<0.05). On multivariate logistic regression analysis, NAFLD was an independent risk factor [Odds ratio (OR) 1.45, 95% confidence interval (CI) 1.07-1.98] for adenoma formation after a negative baseline colonoscopy. The risk of colorectal adenoma increased when NAFLD patients had other morbidities including metabolic syndrome, hypertension, or smoking (OR: 2.85, 4.03, and 4.17).

NAFLD is an independent risk factor for colorectal adenoma formation after a negative baseline colonoscopy. The risk is higher in individuals with NAFLD and other co-morbidities such as hypertension, smoking, or metabolic syndrome.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The effect of restorative proctocolectomy (RPC) on fertility and pregnancy in women with ulcerative colitis (UC) was evaluated.

Post-RPC female UC patients attempting to become pregnant filled out questionnaires on fertility and pregnancy. Demographic and pouch data of pregnancies ending with delivery were collected from a prospective database.

Forty-one women aged 44 ± 10 years completed the questionnaires. The median follow-up period post-RPC was 167 (20-352) months. Before RPC, 26 had 70 pregnancies and 62 deliveries. After RPC, 17 had 32 pregnancies and 26 deliveries (P = 0.0035). Post-RPC, 10/27 (37%) patients failed to conceive compared with 26/26 successful attempts before RPC (P = 0.0006). The number of offspring per patient was 2.38 ± 1.27 before and 0.68 ± 0.93 afer RPC (P < 0.0001). More spontaneous pregnancies occurred before (56/62, 90%) than after (15/25, 60%) RPC (P = 0.0004). The time to conception was longer (5.0 ± 11.6 vs. 16.3 ± 25.1 months, P = 0.039) and there were more in-vitro fertilization procedures (3 vs. 6) post-RPC. The gestation period was similar, but after RPC more deliveries were by Cesarean section (12.9% vs. 46.2%, P = 0.0007). Post-RPC offspring weighed less (3.16 ± 0.61 v 2.79 ± 0.68 kg, P = 0.0327).

RPC is associated with an increased risk of infertility, similar gestation duration and lower birth weight. Female candidates for RPC who have not finished family planning should be counseled accordingly.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The safety, feasibility and oncologic results were evaluated of laparoscopic resection for advanced colon cancer.

Seventy consecutive patients with a histologically proven T4 colon cancer who underwent laparoscopic (LPS) right or left colectomy were matched for co-morbidity on admission (ASA score), tumour stage and grading with 70 patients who underwent open colectomy over a 10 year period. Short and long-term outcome measures were evaluated.

The overall conversion rate was 7.1 %. A less intraoperative blood loss (P = 0.01), a trend toward a longer operative time (P = 0.09) and a lower perioperative blood transfusion rate (P= 0.06) were observed in the LPS group. A similar number of lymph nodes was retrieved (P = 0.37) and the R1 resection rate (P = 0.51) was no different in the two groups. The overall mortality rate was 1.4 %. The overall morbidity rate was 21.4 % (15/70 pts) in the LPS and 27.5 % (19/70 pts) in the open group (P = 0.42), with anastomotic leakage rates of 7,1 % and 4.2% (P = 0.32). Length of stay was shorter after LPS (P = 0.009). Five-year overall (P = 0.18) and disease-free survival rates (P = 0.20) did not significantly differ between the two groups.

Laparoscopic treatment of T4 colon cancer is safe and feasible and provides a similar surgical and oncologic outcome when compared with open technique.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

There are conflicting data on the biological and prognostic significance of disseminated tumour cells (DTCs) in the bone marrow of colorectal cancer patients since bone metastasis are rare in this disease. The study aimed to determine the origin of bone marrow -DTCs using human colorectal cancer cells in in vivo and in vitro experimental settings.

CD1 nude female mice were xenotransplanted with SW620 cells (colorectal cancer cell line isolated from a male patient) injected in the colon wall. At autopsy, the presence of SW620 in the bone marrow (BM), colon and other organs/tissues was recognized by detection of the epithelial marker cytokeratin-19 (CK19) and Y-chromosome. In addition SW620 cells or their conditioned media were cultured with human BM cells.

Macroscopically evident CK19+/Y-chromosome+ tumours developed only in five mice receiving SW620 cells while putative DTCs (CK19+) were found in the bone marrow of all treated mice. Most of these CK19+ cells were Y-chromosome-negative, only few being Y-chromosome-positive. In vitro SW620 cells or their conditioned medium induced CK19 expression in cultured human bone marrow cells.

Experimental colorectal cancer can induce the appearance of two distinct CK19+ cell populations in the bone marrow, one of metastatic origin and the other of murine origin. These findings suggest that bone marrow cells may undergo phenotypic modifications induced by cancer cells.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Endoscopic resection is the primary treatment for colorectal adenoma, but in some cases surgery is necessary. The aim of this retrospective study was to define the prevalence and predictive factors for surgery in patients with advanced colorectal adenoma managed in a referral endoscopy centre.

Consecutive patients diagnosed with advanced adenoma (class 4 in the Vienna classification) during a colonoscopy from 2007 to 2009 in the endoscopy centre of the University Hospital of Rennes were included. Predictive factors of surgery were determined by univariate and multivariate analysis.

Two hundred and twelve (135 male) patients with a mean age of 65.8 years were included. The reason for colonoscopy was for diagnosis in 63.2%, surveillance in 25.5% and screening in 11.3%. These referred patients amounted to 20.8% of all cases having colonoscopy. Surgery was performed in 13.7% of the 212 cases and in 16 (8.3%) of the 192 patients in whom endoscopic removal was attempted. In the subgroup of 192 patients, univariate analysis revealed that body mass index (p=0.04), histology (p=0.002), size (p=0.03), and macroscopic appearance (p<0.001) of the polyp were associated with surgery. Multivariate analysis revealed that the macroscopic appearance and histology only were significantly associated with surgery.

Surgery was needed in 13.7% of patients with an advanced adenoma, but in only 8.3% of the subgroup of 192 patients in whom endoscopic removal was attempted. Factors associated with surgery included macroscopic appearance and histology.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

A recent study of unplanned reoperation within 28 days after colorectal surgery in England found a mean rate of 6.5% and suggested that this be used as a performance indicator. We aimed to find the unplanned 30 day reoperation rate for patients having colorectal cancer surgery in NHS Lanarkshire.

This retrospective study identified all patients having surgery for colorectal cancer in NHS Lanarkshire between 2006-2008 from a prospective colorectal cancer database. Scottish Morbidity Record (SMR01) data were then examined for each patient to determine whether they returned to the operating theatre within 30 days of the index procedure.

573 patients had a primary operation for colorectal cancer during the period. The unplanned rate of reoperation within 30 days of surgery was 5.4%. There was no statistically significant difference between the hospital site, emergency or elective operation or laparoscopic resection or laparotomy. There was no statistically significant difference in reoperation rate between colorectal and general surgeons.

The rate of unplanned reoperation in NHS Lanarkshire compares favourably to that of England however similar methodological problems exist. The accuracy of the data is dependent on coding and entry.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Postoperative oral nutritional supplementation is becoming a part of most patient care pathways. This study examined the effects of low volume high calorie prescribed supplemental nutrition on patient outcome following elective colorectal surgery.

Patients undergoing elective colorectal resections were randomised to receive prescribed nutritional supplementation group (SG) - [standard diet + 6 x 60 mls/day of Pro-Cal*] or conventional postoperative diet group (CG) - [standard diet alone]. Preoperative and daily postoperative hand grip strengths (GS) were measured using a grip dynamometer after randomisation. Daily food intake, return of bowel activity, nausea score for the first 3 days and postoperative length of hospital stay (LOS) were prospectively recorded. Micro-diet standardised software was used to analyse food diaries. Non-parametric tests were used to analyse the data.

Fifty five patients were analysed (SG: 28; CG: 27). There was no difference in median preoperative and postoperative handgrip strengths at discharge within each group (SG: 31.7 v/s 31.7; p=0.932 & CG: 28 Kpa v/s 28.1 Kpa; p=0.374). The total median daily calorie intake was higher in SG than CG (SG: 818.5Kcal v/s CG: 528Kcal; p=0.002). There was no difference in median number of days to first bowel movement (SG: 3d v/s CG: 4d; p=0.096). The median LOS was significantly shorter in SG than CG (6.5 v/s 9d; p=0.037).

Prescribed postoperative high calorie low volume oral supplements, in addition to the normal dietary intake is associated with significantly better total daily oral calorie intake and may contribute to a reduced postoperative hospital stay.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Laparoscopic Ventral mesh rectopexy (LVMR) is increasingly recognised as having utility in rectal prolapse, obstructed defaecation (ODS), faecal incontinence (FI) and multi-compartment pelvic floor dysfunction (PFD). This study aimed to highlight gaps in service provision and areas for improvement by examining a cohort of patients with complications referred to a tertiary center.

Examination was carried out of a password protected electronic database of all LVMRs operated on in one institution.

50 patients (45 female) aged 24-71 (median 54) years were referred with early symptomatic failure (n=27) following an inadequate LVMR or major mesh complications (erosion into other organ, fistulation, stricturing) (n=23). All were amenable to remedial laparoscopic surgery. Functional improvements in pre- and postoperative ODS, Wexner (FI) scores (two tailed t test; p<0.0001) and QoL (BBUSQ-22) scores at 3 months (two tailed t test; p<0.001) and normalization at one year (p<0.015). This was mirrored by improved Linear Bowel Severity VAS scores (two tailed t test; p < 0.0001 [3/12] and p = 0.0151 [at 1 year].

LVMR can be associated with technical complications arising from inadequate technique, or operation specific complications that are amenable to complex revisional laparoscopic surgery with significant improvement in quality of life and function.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

This study was carried out to clarify the clinical features of acute haemorrhagic rectal ulcer (AHRU) and to determine the risks and predictors of AHRU rebleeding.

Forty patients with AHRU were retrospectively analysed. Patient characteristics, endoscopic features and clinical course were investigated and predictors of AHRU rebleeding were analysed.

All patients were in a bedridden state due to various diseases,and many patients had atherosclerosis-related comorbidities such as hypertension (67.4%), diabetes mellitus (40.0%) and chronic kidney disease (42.5%). All patients had hypoalbuminaemia, 75% of patients were using antithrombotic drugs and 25% of patients were using systemic corticosteroids. Based on colonoscopy, all patients developed ulcers in the distal rectum just above the dentate line and 30% of patients developed whole circumferential ulcers. The median interval between the onset of the bedridden state and the first massive haematochezia was 16 days and 50% of all patients developed rebleeding regardless of the presence or absence of haemostatic therapy. The median time from initial haemostasis to rebleeding was 6 days. Univariate analysis and stepwise multivariate analysis revealed that whole circumferential ulcer (p=0.036) was a significant independent predictor of AHRU rebleeding.

In the present study, we elucidated the clinical features of AHRU in detail and reviewed previous reports of AHRU. Rebleeding of AHRU occurred at a high rate and whole circumferential ulcer was a significant independent predictor of AHRU rebleeding.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The study prospectively audited adverse events for surgical patientswith colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events.

Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996-2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality (SASM).

In the 10 year study period,3029 patients with colorectal cancer, mean age 76(13-105) yearsdied under surgical care of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) of whom1030(34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P=0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P=0.009), a 37% fall for surgical care (P=0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P=0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P=0.016).

The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Inguinal nodes may be a possible route for lymphatic spread in patients with distal rectal cancer. The outcome was examined of patients with distal rectal cancer undergoing neoadjuvant CRT and having FDG-avid inguinal nodes using PET/CT imaging.

99 consecutive patients with cT2-4N0-2M0 distal rectal adenocarcinoma were enrolled in a clinical trial NCT00254683 and underwent baseline PET/CT followed by 54Gy and 5FU-based CRT. After CRT, patients underwent 6-week and 12-week PET/CT. Patients with positive inguinal node uptake were compared with patients with negative uptake. The inguinal region was not included in the field of radiation therapy.

17 (17%) patients had baseline positive inguinal node FDG uptake. They were more likely to have the tumour closer to anal verge (2.0cm vs. 4.2cm; p=0.001). Of these, eight (47%) demonstrated a positive inguinal uptake at PET/CT after 12 weeks from CRT. Patients with inguinal node FDG uptake after CRT (positive PET at baseline and 12 weeks) had a significantly worse 3-year overall and disease-free survival (p=0.02 and p=0.03). After a median follow-up period of 22 months, none of these patients had developed inguinal recurrence.

Uptake of inguinal nodes at PET/CT may be present in up to 17% of patients with distal rectal cancer, particularly with ultra-low tumours. Nearly half of these nodes no longer show uptake after CRT despite the groin area not being included in the radiation field. Persistence of inguinal node uptake after 12 weeks of CRT completion may be a marker for worse oncological outcome.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Patients with hereditary non-polyposis colorectal cancer (HNPCC) seem to have a better prognosis than those with sporadic colon cancer (CC)s. The aim was to compare survival after stage III CC in patients with HNPCC with those having sporadic CC.

230 patients with hereditary cancer from The Danish HNPCC-Register and 3557 patients with sporadic CC from The Danish Colorectal Cancer Database, diagnosed during May 2001–December 2008 were included. HNPCC patients were classified according to Mismatch Repair mutation status and family pedigree. Sporadic cases had no known family history of cancer. Patient characteristics, geographic differences and survival data were analyzed.

The overall survival (OS) was better in HNPCC patients compared to sporadic CC after stratification for sex and age (p=0.02; CI 1.04-1.7). The 5-year survival was 70% in HNPCC patients compared with 56% in sporadic CC (p<0.001). No survival difference was found between HNPCC subgroups but a tendency of better OS was seen in patients with Lynch syndrome. No geographic differences in OS were found. The median follow-up was 3.9 (0–9.5) years for HNPCC vs 3.2 (0–9.6) years for sporadic CC.

HNPCC patients with stage III CC have a better OS compared with sporadic CC. Within HNPCC subgroups, no significant difference in OS was found.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Tumour involved circumferential resection margins (CRM) and intra-operative perforation (IOP) are well known risk factors for local recurrence after surgery for low rectal cancer. In conventional abdomino-perineal excision (APE) the patient remains in the supine position for the perineal part of the procedure. However, turning the patient to the prone position may improve visualization which potentially might reduce the risk of involved CRM and IOP and thus improve local control.

The study was carried out to assess local recurrence rates after APE in relation to the positioning of the patient during the perineal part of the procedure.

This cohort study includes 466 patients having APE for low rectal cancer between 2001 and December 2010. Data were retrieved from the regional rectal cancer registry in Stockholm and from a retrospective review of patient files.

An incomplete resection was reported in 12.4% after APE in the supine position and in 6.8% after APE in the prone position (p=0.038). Correspoding figures for IOP were 12.4% and 4.0% (p<0.001). Prone APE was associated with a 39% relative reduction in local recurrence events compared with APE in the supine position, although the difference was not statistically significant, [HR 0.61, (95% CI: 0.27-1.37)].

APE in the prone position reduced the incidence of incomplete resection and IOP, but the study did not find a statistically significant difference in local failure rates related to position of the patient.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The accuracy of computed tomography (CT) was determined in detecting local invasion (T status) and nodal metastasis (N status) of colon cancer.

Data on the preoperative CT scan of 153 lesions from 152 patients with colon cancer were reviwed retrospectively. Evaluation included the T-stage and N-stage of the RNM system. The results were compared to those obtained by histopathological examination of the resected tumour..

Of the 153 tumors, 117 (76.5%) were correctly classified as stage T1 and T2 (33 tumours) and stage T3 and T4 (84 tumours) by CT. The sensitivity and specificity were 70.2% and 79.2%, respectively, and the positive (PPV) and negative predictive value (NPV) were 85.7% and 60.0%. When analyzed according to the individual T stage (Tx/Tis, T1, 2, 3, 4) and N stage (N0, 1, 2), the kappa coefficient with linear weighting was 0.208 (fair agreement) for T stage, and 0.154 (slight agreement) for N stage. The estimation of tumour size estimation showed good agreement with histopathology (Spearman correlation coefficient 0.865).

CT scanning of colonic cancer showed 75% accuracy in identifying T1 and T2 cancers combined, but gave poor agreement between CT and histopathology for individual T stages.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

It is unclear whether colectomy for fulminant C. difficile colitis (FCDC) leads to a improvement in survival compared with continued medical therapy for this moribund population.

Selected studies from 1994-2010 were identified through a comprehensive search theme applied to MEDLINE (OvidSP and PubMed), EMBASE and by hand searching. Data regarding mortality rates between medically and surgically treated patients were extracted. Risk of bias was assessed using a Newcastle-Ottawa Scale score. A meta-analysis of the odds ratios for mortality between surgical and medical treatment for FCDC was conducted using the Mantel-Haenszel method and fixed-effects modeling.

510 patients with FCDC were identified in six studies. The pooled adjusted odds ratio of mortality comparing surgery to medical therapy was 0.70 (0.49-0.99), suggesting that surgery provided a survival benefit.

Emergent colectomy for patients with FCDC provides a survival advantage compared with continuing antibiotics. Though there is selection bias of patients having surgery, the results of this systematic review suggest that colectomy has a therapeutic role in treating severe forms of C. difficile colitis.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Previous reports describing Clostridium difficile colitis (CDC) developing after the closure of a loop ileostomy suggests it is severe. In this study the incidence of CDC following ileostomy closure and its effect on the postoperative outcome have been studied.

Patients undergoing closure of loop ileostomy from 2004-2008 were analyzed using the Nationwide Inpatient Sample. Patients who developed postoperative CDC (n=217) were matched 10:1 to a propensity-score matched cohort of patients without CDC (n=13,245). Linear and logistic regression was used to examine the effect of CDC on hospital cost (US dollars), length of stay (LOS) and mortality rates. Population resampling was performed using nearest neighbour bootstrapping to confirm the validity of results.

The incidence of CDC following ileostomy closure was 16/1000 patients. The mean length of stay (LOS) was 11.5 days longer among CDC patients (p<0.0001), with a greater cost of hospitalization of $21,240 (p<0.0001). There was no difference in mortality between the cohorts.

CDC following ileostomy closure is an uncommon, costly and morbid complication. Patients undergoing stoma closure are at high risk for an adverse outcome if they have CDC. Should it develop they should be aggressively treated.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Lymph node (LN) metastases are present in up to 17% of early colorectal cancers (pT1). Identification of associated histopathological factors would enable counseling of patients regarding this risk.

Pubmed and Embase were employed utilising the terms ‘early colorectal cancer’, ‘lymph node metastasis’, ‘submucosal invasion’, ‘lymphovascular invasion’, ‘tumour budding’ and ‘histological differentiation’. Analysis was performed using Review Manager 5.1.

Twenty three cohort studies including 4510 patients were analysed. There was a significantly higher risk of LN metastasis with a depth of submucosal invasion greater than 1mm than with lesser degrees of penetration (OR 3.87, 95% CI 1.50-10.00, p=0.005). Lymphovascular invasion was significantly associated with LN metastasis (OR 4∙81, 3∙14-7∙37, p<0∙00001). Poorly differentiated tumours had a higher risk of LN metastasis compared with well or moderately differentiated tumours (OR 5.60, 2.90-10.82, p<0∙00001). Tumour budding was found to be significantly associated with LN metastasis (OR 7∙74, 4∙47-13∙39, p<0∙001).

Meta-analysis of the current literature demonstrates that in early colorectal cancer a depth of submucosal invasion by the primary tumour of >1mm, lymphovascular invasion, poor differentiation and tumour budding are significantly associated with LN metastasis.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Surgery is the mainstay of treatment for rectovaginal fistula (RVF). Published success rates vary with initial success being around 50% rising to 80% with repeated surgery. Fistulas in Crohn's disease are more likely to recur.

A retrospective study was performed of rectovaginal fistula repair carried out between 2003 and 2008 in a tertiary referral centre . Patients undergoing surgery for a rectovaginal fistula under the senior author during the study period were identified and their clinical notes reviewed.

Thirty-five patients underwent 50 operations. The median age was 42 years and 83% were tertiary referrals. Two patients were lost to follow-up. Healing occurred in 19 (58%) of 33 patients after a mean of 1.4 operations. The median time to success was 11 (2.5 – 48) months. The ‘curative’ group had an overall success of 73% (19 of 26). Seventy-five percent of non-IBD patients and 67% of those with Crohn's disease had successful treatment of the RVF. Twenty-four of thirty-five patients (67%) underwent creation of a stoma. Sixteen of twenty-four (67%) were deemed fit for restoration of continuity. No demographic or disease related factors were found to influence healing.

Cure of rectovaginal fistula can be achieved by a range of surgical approaches including abdominal and anal. A variety of different anal techniques are necessary, depending on the integrity of the anal sphincter and the presence or absence of perineal descent/internal intussusception.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Early removal of the urethral catheters is part of the enhanced postoperative recovery programme (ERAS). The effect of epidural anaesthesia on urinary retention was investigated in patients after colorectal resection.

A prospective cohort study of all patients having colorectal surgery within an ERAS programme including insertion of an epidural catheter over the last five years.

210 patients had an epidural and a urethral catheter postoperatively. The duration of catheterisation was not recorded in one patient who was therefore excluded from the study. 118 patients had a trial without catheter prior to stopping the epidural (early TWOC). 91 patients had TWOC after the epidural was stopped (late TWOC). Sixteen (7.6%) patients went into retention (14 earl, 2 late TWOC). The rate of urinary retention in the early TWOC group was significantly higher than the late TWOC group (11.9% vs 2.2% χ2, p= 0.009). Those who underwent a laparoscopic resection were significantly more likely to have undergone an early TWOC (χ2, p=0.001), however there was no difference in retention rates between open and laparoscopic surgery (χ2, P= 0.402).

Pelvic surgery was not significantly associated with an increased risk of post-operative retention (χ2, p= 0.627). Male sex was not significantly associated with retention (χ2, p= 0.087). In the early TWOC group 86% had the catheter removed within 24 hours of surgery.

Early TWOC with epidural analgesia running significantly increases the risk of urinary retention, however it was still successful in 88% of patients.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Stercoral perforation is a rarely suspected life threatening condition. Early diagnosis is difficult but essential. A comprehensive systematic review was performed to evaluate its presentation, diagnosis and treatment.

A systematic review was carried out of Embase, Medline, Pubmed and Cochrane databases for all articles between 1998 and 2011. Only studies describing stercoral perforation were included.

24 relevant articles were found including 137 (mean age 64.3 years) cases of stercoral perforation of whom 81% had chronic constipation. The diagnosis was made by CT scan in 90% by faecal impaction (84%) and subphrenic (90%) or extraluminal air (61%). The commonest site of perforation was the sigmoid (42%) followed by the rectosigmoid junction (23%). The overall mortality was 34%.

Stercoral perforation should be suspected in elderly and chronically constipated patients with unexplained abdominal pain and investigated appropriately with a CT scan to allow timely and optimal treatment.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

Laparoscopic ventral rectopexy (LVR) is a non-resectional technique for selected patients with full thickness rectal prolapse and obstructed defecation syndrome. Despite its challenges, LVR can be performed with relatively minimal patient trauma thus creating the potential for same-day discharge. Our aim was to assess the safety of day-case LVR and identify factors associated with same-day discharge.

Data were prospectively collected on all patients (n=120) from June 2008 to October 2011. Variables included demographics, peri-operative details and post-operative course. Primary outcome was length of stay and secondary outcome was symptom improvement at the latest outpatient follow-up. Patients discharged the same-day after LVR were compared to those who stayed overnight or longer.

Indications included rectocele and internal prolapse (47%), full thickness rectal prolapse (44%) and other (9%). Mean operative time was 97 minutes, same-day discharge occurred with 23% (n=27) and 67% (n=80) were discharged on postoperative day 1. In terms of complications – 89% none, 8% minor and 3% major, including one 24-hour readmission for pain. Logistic regression identified younger age (p=0.054) and private insurance status (p<0.001) as being significantly associated with same-day discharge. Although surgical indication (p<0.001), no prior hysterectomy (p=0.012) and use of biologic mesh (p=0.012) had significant association they were likely confounded by age.

In selected patients with rectal prolapse or obstructed defecation, same-day discharge after LVR is feasible and safe. Our analysis identified quicker discharge in the private system with younger patients. Nevertheless, in unselected patients 90% were discharged by the first operative day.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The barostat can be used to measure rectal sensitivity, compliance and elastance all of which are potentially important physiological parameters in the pathophysiology of faecal incontinence. Current practice recommends a conditioning distension sequence be performed prior to index distensions. We questioned the validity of this by comparing values for rectal compliance during sequential conditioning (CD) and index (ID) distensions in physiologically normal subjects.

10 subjects (5 male, mean age 55.2 years)with normal anal canal manometry, anorectal sensitivity and balloon distension thresholds were studied. After determining the minimum distension pressure, subjects underwent sequential isobaric distensions: CD 4mmHg distensions every 45 seconds and ID 4mmHg every 2 minutes, both to a maximum of 24mmmHg or patient tolerance. Compliance values from both sequences were calculated by measuring the maximum slope of pressure-volume curves. A paired t test was performed to compare any differences between sequences.

Mean rectal compliance were 11.4ml/mmHG (SD 5.8ml/mmHG) and 10.9ml/mmHg (SD 5.7ml/mmHg) in the CD and ID respectively with no statistical difference noted between distensions (p=0.78).

Rectal compliance can be measured with a single distension protocol without the need for an initial conditioning distension. Conditioning the rectum adds additional complexity to barostat protocols and is not necessary.

© 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland

The aim of this retrospective study was to determine patient and treatment characteristics with corresponding clinical outcome of symptomatic chronic presacral sinus after low anterior resection.

Twenty two patients were treated for a presacral sinus persisting for at least 12 months after low anterior resection for rectal carcinoma between January 2005 and March 2012. Patient charts were reviewed and analyzed using descriptive statistics.

Fistula formation was the most frequently observed secondary complication in 55% of patients. A median of 6 (1-44) surgical, endoscopic or radiological interventions related to the presacral sinus were performed. The chronic presacral sinus healed spontaneously in nine (41%) patients at a median interval from primary surgery of 45 (24-93) months. Following basic treatment principles salvage surgery in the form of anastomosis or completion proctectomy resulted in healing in 8 (62%) of the 13 patients who underwent surgery.

Successful treatment of a chronic presacral sinus after low anterior resection appears to be achieved spontaneously or either by salvage surgery with anastomotic reconstruction in highly selected patients or intersphincteric completion proctectomy and omentalplasty.

© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland

An evaluation was performed of the one-year outcome of open haemorrhoidectomy (Milligan-Morgan alone or with posterior mucosal anoplasty [Leopold Bellan procedure]).

A prospective, multicentre, observational study included all patients having a planned haemorrhoidectomy from January 2007 of June 2008. Data were collected before surgery, at three months and one year after surgery. Patients assessed their anal symptoms and quality of life (SF-36).

633 patients (median age 48 years, 56.5% female) underwent haemorrhoidectomy including Milligan-Morgan alone (n=231, 36.5%) or the Leopold Bellan procedure (posterior mucosal anoplasty) for resection of a fourth haemorrhoid (n=345, 54.5%), anal fissure (n=56, 8.9%) or low anal fistula (n=1, 0.16%). Median healing time was 6 weeks. Early complications included urinary retention (n=3), bleeding (n=11), local infection (n=7) and faecal impaction (n=9). At one year, main complications included skin tags (n=2) and anal stenosis (n=23). There were three recurrences requiring a second haemorrhoidectomy. On a visual analogue scale, anal pain at one year had fallen from a median of 5.5/10 before treatment to 0.1/10 (p<0.001), anal discomfort from 5.5/10 to 0.1/10 (p<0.001) and the KESS constipation score from 9/45 to 6/45 (p<0.001). The median Wexner score for anal incontinence was unchanged (2/20). De novo anal incontinence (Wexner >5) affected 8.5% of patients at one year, but preoperative incontinence disappeared in 16.7% of patients with this symptom. All physical and mental domains of quality of life significantly improved and 88% of patients were satisfied or very satisfied.

Complications of open haemorrhoidectomy were infrequent. Anal continence was not altered. Comfort and well-being were significantly improved at one year after surgery. Patient satisfaction was high despite residual anal symptoms.

© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland

This review aimed to assess the published results of posterior tibial nerve stimulation (PTNS) for faecal incontinence.

A search was performed of PubMed, MEDLINE and Embase to identify studies describing the clinical outcome of PTNS for faecal incontinence.

Thirteen studies were identified. These described the outcome of PTNS for faecal incontinence in 273 patients. Four described transcutaneous PTNS, eight percutaneous PTNS and one compared both methods of PTNS with a sham transcutaneous group. One investigated patients with faecal incontinence and spinal cord injury and another with inflammatory bowel disease. There was marked heterogeneity of the treatment regimens and of the end points used. All reported that PTNS improved faecal incontinence. A > 50% improvement was reported in episodes of faecal incontinence in 63–82% of patients. An improvement was seen in urgency (1–5 min). Improvement was also described in the Cleveland Clinic faecal incontinence score in eight studies. Patients with urge and mixed incontinence appear to benefit more than those with passive incontinence. Treatment regimens ranged in duration from 1–3 months. A residual therapeutic effect is seen after completion of treatment. Follow-up ranged from 1–30 months.

PTNS is effective for faecal incontinence. However, many of the published studies are of poor quality. Comparison between studies is difficult owing to differences in the outcome measures used, technique of PTNS and the timing and duration of treatment.

Over the last 5 years, the ligation of the intersphincteric fistula tract (LIFT) procedure has become increasingly popular as a sphincter-preserving technique for the treatment of anal fistula. The aim of this article was to review the published literature on the LIFT procedure.

The Cochrane database and EMBASE were searched from January 1980 to November 2012, and PubMed from January 1966 to November 2012. All peer-reviewed studies that investigated the LIFT procedure for the treatment of anal fistula were eligible for inclusion. Technical notes, commentaries, letters and meeting abstracts were excluded. The primary outcome measured was the overall fistula closure rate in relation to the length of follow-up.

Twenty-nine articles were originally identified using the search criteria. Thirteen were finally included for analysis. Sample sizes ranged from 18 to 93 patients, with a pooled total of 498. Most fistulae, 494 (99%), were of cryptoglandular aetiology, of which 470 (94%) were transsphincteric. Overall success rates ranged from 40 to 95%, with a pooled success of 71% (352 of 495 patients; 3 of 498 were lost to follow-up). Follow-up ranged from 1 to 55 months, with a reported mean or median of 4 to 19.5 months. One hundred and eighty-three patients were formally assessed for continence, out of whom 11 (6%) had a minor disturbance.

Overall the systematic review shows that the LIFT procedure appears to be an effective sphincter-conserving approach for the treatment of transsphincteric anal fistula with a pooled healing rate of 71% over a mean or median follow-up period ranging from 4 to 19.5 months.

Neoadjuvant chemotherapy may have a role in the management of colonic carcinoma but clinical trials are required to determine whether this approach is superior to the standard policy of radical surgery, high-quality histopathology and selective postoperative chemotherapy. The selection of appropriate patients for such trials will depend on accurate locoregional staging of disease by preoperative CT scanning. We studied the outcome after radical right hemicolectomy and assessed the accuracy of preoperative CT scans in the prediction of postoperative pathology.

A retrospective analysis of right hemicolectomies performed with curative intent for colon cancer under the care of a single colorectal surgeon (D.J.A.) was performed. Preoperative CT-proven Dukes D patients were excluded. Patient demographics, postoperative histology, use of adjuvant chemotherapy and survival data were collected. Kaplan–Meier curves were constructed and log-rank testing was performed to compare cancer-specific survival. Fifty patients had their preoperative CT scan images reviewed by two radiologists both blinded to the results of the postoperative histology. The accuracy of preoperative CT for T and N staging was studied. A P-value of < 0.05 was significant.

There were 136 patients (79 women). Median age was 76 (interquartile ratio 67–82) years. Median period of follow-up was 72 (interquartile ratio 39–92) months. There were 56 deaths (39 medical, 16 oncological and 1 postoperative). There were three groups of patients: node negative (n = 84), node positive with postoperative adjuvant chemotherapy (n = 30) and node positive without chemotherapy (n = 22). Five-year cancer-specific survival for node negative disease was 84% and was poorer for node positive patients who received adjuvant chemotherapy when compared with those who did not (62 vs 72%, P-value = 0.046 on log-rank testing). Sensitivity, specificity, positive and negative predictive value of CT scan for tumour (T) stage were 90, 33, 86 and 43% respectively, while that for nodal (N) stage was 83, 38, 57 and 69%, respectively.

CT scan has limited accuracy in predicting those patients with advanced locoregional disease who might benefit from neoadjuvant treatment. When this finding is combined with relatively high cancer-specific survival with surgery alone the impact of adjuvant chemotherapy on survival after radical surgery for right colon carcinoma may be marginal.

The Spanish Rectal Cancer Project was established in 2006, inspired by the Norwegian Rectal Cancer Project. It consisted of an educational project aiming to introduce mesorectal excision surgery to surgeons, pathologists and radiologists. Its effect on local recurrence (LR) was compared with the Norwegian Project.

An observational cohort study was carried out including all patients (4700) with rectal cancer from a population of 19 329 992 inhabitants operated on in 51 Spanish hospitals between March 2006 and June 2010. Curative resection was defined as a resection with an uninvolved circumferential margin in patients without distant metastases and without intra-operative rectal perforation. The effectiveness of the programme was measured by a central registry with feedback to participating institutions of their own results compared with the national average. The main outcome measures were LR and adverse effects in curative resections.

Of the 4700 patients, 3213 had a resection considered to be curative. LR rates were 4.7% (95% CI 0.03–0.59), metastasis rate was 16% (95% CI 0.14–0.17) and overall survival was 87.8% (95% CI 0.86–0.89). Multivariate analysis showed that advanced TNM stage and decreasing distance of the tumour from the anal verge had a negative influence on LR.

This study shows that the results obtained in Norway have been reproduced in a larger population in Spain applying a similar methodology.

Preoperative chemotherapy followed by radical surgery is an attractive treatment for locally advanced colon cancer (LACC) given the promising results of this approach in other locally advanced tumours. The study evaluates the outcome and treatment-related complications of perioperative oxaliplatin- and capecitabine-based chemotherapy and surgery for clinical Stage III colon cancer.

Twenty-two consecutive patients with a CT-staged LACC were included. All were staged at baseline and before surgery. Surgery-related complications and oncological outcome were determined.

Toxicity was manageable, with 19/22 patients completing the planned chemotherapy protocol. The median time from initial diagnosis to surgery was 65.5 days. The median time from the end of chemotherapy to surgery was 22 days. After neoadjuvant treatment, tumour reduction of 69.5% was observed by CT scan and a 59.9% decrease of SUV_max (standard uptake value) was achieved on positron emission tomography/CT. No progressive disease was reported during preoperative chemotherapy and surgery was performed in all 22 patients. Four patients developed postoperative complications. After a median postoperative follow-up of 14.4 months, the actuarial overall and disease-free survival rates were 100 and 90%.

Neoadjuvant chemotherapy followed by surgery and chemotherapy for LACC is safe without apparent increase of early and medium-term complications.

This study involved a large nationwide Danish cohort to evaluate the hypothesis that a high lymph node harvest has a positive effect on survival in curative resected Stage I–III colon cancer and a low lymph node ratio has a positive effect on survival in Stage III colon cancer.

Analysis of overall survival was conducted using a nationwide Danish cohort of patients treated with curative resection of Stage I–III colon cancer. All 8901 patients in Denmark diagnosed with adenocarcinoma of the colon and treated with curative resection in the period 2003–2008 were identified from the Danish Colorectal Cancer Group (DCCG). The impact of lymph node count and lymph node ratio was analysed.

Overall 5-year survival was 56.8 and 66.6%, (P < 0.0001) for lymph node counts of fewer than 12 and 12 or more, respectively. The percentages of lymph node positive patients in the two groups were 29.8 and 40.3% (P < 0.0001), respectively.

When putting the Stage III patients into four subgroups according to the lymph node ratio (cut-off points 1/12, 1/4 and 1/2) we found an overall 5-year survival rate of 68.1, 57.2, 49.3 and 32.4% (P < 0.0001). Lymph node count and lymph node ratio were independent prognostic factors in multivariate analysis.

High lymph node count was associated with improved overall survival in colon cancer. Lymph node ratio was superior to N-stage in differentiating overall survival in Stage III colon cancer. Stage migration was observed.

Rectal bleeding may occur late after radiotherapy for prostate or bladder cancer, particularly when given by external beam, due to radiotherapy-induced haemorrhagic telangiectasia (RIHT). We present the results of trans-anal rectoscopic ball diathermy (TARD) for RIHT.

Data were collected from patients who received TARD for RIHT. The diagnosis was made during endoscopic examination. Treatment involved discretely spaced spot monopolar diathermy coagulation of the rectal mucosa to the affected areas.

Thirteen patients [median age 76 (69–80) years] underwent TARD for RIHT between 2005 and 2008. All presented late with rectal bleeding following radiotherapy for prostate or bladder cancer. Eight were treated as a day case, four remained in hospital for one night and one was hospitalized for 2 days. There was no mortality. Eleven patients achieved excellent symptomatic control requiring no further treatment at a median follow-up of 20 (3–36) months. One patient underwent further TARD for recurrence. One patient complained of severe anorectal pain of no obvious cause and one developed constipation.

Trans-anal rectoscopic ball diathermy (TARD) is a safe and effective treatment for patients with rectal bleeding due to RIHT.

Randomized, controlled trials have demonstrated the efficacy and safety of injectable bulking agents for the treatment of faecal incontinence (FI), although the long-term outcome has not been assessed. NASHA/Dx gel, a biocompatible, nonallergenic bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer microspheres, has demonstrated efficacy and safety for up to 12 months after treatment. The objective of this study was to evaluate the long-term efficacy and safety of NASHA/Dx, assessed 24 months after treatment.

This study was a 24-month follow-up assessment of patients treated with NASHA/Dx under open-label conditions. Data on FI episodes and quality of life measures were collected from diaries over the 28-day period immediately preceding the 24-month assessment. Adverse events were collected.

Eighty-three of 115 patients completed the 24-month follow-up assessment. At 24 months, 62.7% of patients were considered responders and experienced a ≥ 50% reduction in the total number of FI episodes. The median number of FI episodes declined by 68.8% (P < 0.001). Episodes of both solid and liquid stool incontinence decreased. The mean number of incontinence-free days increased from 14.6 at baseline to 21.7 at 24 months (P < 0.001). Incontinence scores and FI quality of life scores also showed significant improvements. The most common adverse events (AEs) were proctalgia (13.3%) and pyrexia (9.6%). The majority of AEs were mild to moderate, self-limited and resolved within 1 month of the injection.

NASHA/Dx is safe, effective and durable over a 24-month period with a majority of patients experiencing significant improvement in multiple symptoms associated with FI.

The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short- and long-term efficacy of LVMR in treating SRUS.

Forty-eight patients with SRUS who underwent LVMR over a 15-year period (December 1996 to July 2012) were identified from a prospectively maintained electronic database.

Forty-eight patients, 38 (79%) women, median age 43 (18–80) years, median body mass index 26 (21–40) kg/m² underwent LVMR for SRUS after initial biofeedback. The median follow-up was 33 months (95% CI 31–55, range 1–186 months); 52% were followed for more than 3 years and 13 (27%) for more than 5 years. Five (10%) had relapsed following a response to stapled transanal rectal resection (STARR; 10 additional patients have had a continued response to STARR). Eleven (23%) had intermittent reducible external prolapse. Epithelial ulcer healing was reported in all patients at 3 months. The ODS scores improved by 68% (P < 0.0001) and quality of life (QoL; Birmingham Bowel and Urinary Symptoms Questionnaire-22) scores improved by 45% (P < 0.0001). There was a significant improvement in bowel visual analogue scale (VAS) scores at 3 and 12 months (P = 0.0007). Sustained improvement in QoL and VAS scores was maintained at 2 years and continued in the 52% followed up for between 3 and 15 years. There were four (8%) symptomatic ODS recurrences: posterior rectal wall prolapse successfully treated by STARR (3) and one symptom free for 2 years following a temporary loop ileostomy. There were two recurrences (4%).

LVMR appears to provide a sustained improvement in QoL, VAS and patient satisfaction in patients with SRUS. Morbidity, recurrence and safety profiles are low.

Ligation of the intersphincteric fistula tract and reinforcement with a bioprosthetic graft are two recently reported procedures that have shown promise in the treatment of anal fistula. This study was undertaken to validate combining ligation of the intersphincteric fistula tract plus bioprosthetic anal fistula plug and report our preliminary results and experience.

Twenty-one patients with transsphincteric anal fistula were treated with ligation of the intersphincteric fistula tract plus concurrent bioprosthetic plug of the anal fistula. We evaluated healing time, fistula closure rate and postoperative anal function according to the Wexner continence score.

No mortality or major complications were observed. Median operative time was 20 (range 15–40) min. After a median follow-up of 14 (range 12–15) months, the overall success rate was 95% (20/21), with a median healing time of 2 (range 2–3) weeks for external anal fistula opening and 4 (range 3–7) weeks for intersphincteric groove incision. Only 1 (5%) patient reported rare incontinence for gas postoperatively (Wexner score 1).

Ligation of the intersphincteric fistula tract plus a bioprosthetic anal fistula plug is an easy, safe, effective and useful alternative in the management of anal fistula. Further randomized controlled studies are necessary to better evaluate long-term results.

Ligation of the intersphincteric fistula tract (LIFT) is a novel sphincter-preserving technique for anal fistula. This pilot study was designed to evaluate the results in patients with a recurrent fistula.

Seventeen patients [nine men; median age 49 (range, 30–76) years] with a recurrent trans-sphincteric fistula were treated with a LIFT procedure between June 2008 and February 2011. All were followed prospectively for a median of 16 (range, 5–27) weeks with clinical examination. Fifteen followed for 13.5 (range, 8–26) months by clinical examination also had three-dimensional (3D) anal ultrasound.

The duration of the procedure was 35 (range, 18–70) min. One patient developed a small local haematoma and one had a subcutaneous infection, but otherwise there was no morbidity. At follow up, 11 (65%) patients had a successful closure, two (12%) had a remaining sinus and four (23%) had a persistent fistula. The incidence of persistent or recurrent fistulae at 13.5 months was six (40%) of 15 patients. No de novo faecal incontinence was reported.

LIFT is a safe procedure for patients with recurrent anal fistula, with healing at short-term and medium-term follow-up comparable with or superior to that of other sphincter-preserving techniques. Larger studies with a longer follow up are needed to define the ultimate role of LIFT in patients with recurrence.

This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses.

A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified.

Thirty-two patients of median age 41 (21–64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2–18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3–24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038).

Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

Although perianal streptococcal dermatitis (PSD) is well known in children, it has only rarely been documented in adults. The incidence and necessity for treatment may be underestimated. We have retrospectively identified adult patients with perianal streptococcal dermatitis.

Patients with streptococcal anal dermatitis were identified from a prospective office database. Treatment was with oral antibiotics according to the organism sensitivity. Additional concomitant anorectal disease was treated according to standard guidelines. Patients were compared with a control group, without eczema or erythema, for the presence of β-haemolysing Streptococci on perianal swab. Demographic and microbiological data were assessed and compared between and within treatment and control groups.

Fifty-three (22 female) patients older than 20 (mean = 49) years of age were diagnosed with perianal streptococcal dermatitis between 2005 and 2009. In most cases group B β-haemolytic Streptococci were found. Fifty patients received antibiotics for 14 days. In 28 of 33 patients who had a post-treatment swab, the result was negative. Five patients showed Streptococci of different groups in the post-treatment swab. Of the 50 patients, 21 (42%) had no further anorectal complaint and 29 (58%) required continuing treatment for another anorectal condition. In the control group β-haemolysing Streptococcus was found in 34%. Men over 60 years of age more often required no further anorectal treatment compared with women (P < 0.05).

Perianal streptococcal dermatitis occurs in adult patients more often than reported. It is mainly caused by group B β-haemolysing Streptococcus. Its diagnosis is important because it can cause serious systemic infections, especially in the elderly and in newborns. Antibiotics resolve the condition in a high proportion of patients.

The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening.

Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008.

In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007–2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007–2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007–2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007–2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007–2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period.

Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample.

A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006–2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death.

In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82–0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16–1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24–2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09–1.52; Medicaid OR = 1.55, 95% CI: 1.22–1.97; uninsured OR = 1.41, 95% CI: 1.07–1.87).

In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.

To determine the diagnostic value of serological infection markers and body temperature in discriminating complicated from uncomplicated diverticulitis.

Patients in whom diverticulitis was pathologically or radiologically proven at presentation were included. Patients were classified as either complicated (Hinchey Ib, II, III and IV) or uncomplicated (Hinchey Ia) diverticulitis. The discriminative value of C-reactive protein (CRP), white blood cell (WBC) count and body temperature at presentation was tested.

A total of 426 patients were included in this study of which 364 (85%) presented with uncomplicated and 62 (15%) with complicated diverticulitis. Only CRP was of sufficient diagnostic value (area under the curve 0.715). The median CRP in patients with complicated diverticulitis was significantly higher than in patients with uncomplicated disease (224 mg/l, range 99–284 vs 87 mg/l, range 48–151). Patients with a CRP of 25 mg/l had a 15% chance of having complicated diverticulitis. This increased from 23% at a CRP value of 100 mg/l to 47% for 250 mg/l or higher. The optimal threshold was reached at 175 mg/l with a positive predictive value of 36%, negative predictive value of 92%, sensitivity of 61% and a specificity of 82%.

WBC count and body temperature are of no value in discriminating complicated from uncomplicated diverticulitis. Only CRP can be used as an indicator for the presence of complications, but a low CRP does not mean that complicated disease can safely be excluded. Therefore, radiological examination remains central in the diagnostic work-up of patients presenting with diverticulitis.

The aim of this review article was to outline current evidence relating to the treatment and prevention of parastomal herniation with a view to guide surgeons dealing with patients potentially affected by this complication.

Medline and PubMed databases were searched using the keywords ‘parastomal hernia/herniation’, ‘stoma hernia/herniation’ and ‘stoma complications’. Evidence was obtained from randomized and non-randomized studies. Case reports and articles not written in English were excluded. Qualitative assessment of all included studies was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence.

The search revealed a total of 228 publications of which 115 fulfilled the selection criteria. Stoma formation through the rectus muscle is complicated by parastomal herniation in up to 50% of cases. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. The ‘Sugarbaker’ technique appears to be superior to the ‘keyhole’ technique when a laparoscopic approach is used. Prophylactic mesh reinforcement of the stoma trephine appears to reduce the herniation rate to approximately 15% and is accompanied by a decrease in symptomatic hernias requiring repair without any difference in stoma-related morbidity.

Large prospective controlled trials are required to compare surgical techniques of stoma formation in reducing the incidence of parastomal herniation. Despite limited evidence, routine prophylactic mesh reinforcement of the stoma trephine should be offered to all patients undergoing permanent stoma formation.

As a consequence of the improved survival of patients and of cost-effectiveness requirements for new treatments, health-related quality of life (HRQoL) issues have gained increasing attention in colorectal cancer (CRC). This cross-sectional study assesses HRQoL in several health states of CRC and explores factors influencing HRQoL.

Five hundred and eight Finnish CRC patients (aged 26–96 years; colon cancer 56%; women 47%) assessed their HRQoL using generic 15D and EQ-5D and cancer-specific EORTC QLQ-C30 questionnaires. Patients were divided into five groups: primary treatment, rehabilitation, remission, metastatic disease and palliative care. The patients' HRQoL was compared with population reference values. Multivariate modelling was used to find factors associated with HRQoL scores.

The HRQoL of CRC patients is fairly good and comparable with that of the standardized general population except for those under palliative care. The mean 15D score of patients in the primary treatment group was 0.889 (95% CI 0.869–0.914), in rehabilitation 0.877 (0.855–0.907), in remission 0.886 (0.875–0.903), in metastatic disease 0.860 (0.844–0.878) and in palliative care 0.758 (0.716–0.808). The respective EQ-5D scores were 0.760 (0.699–0.823), 0.835 (0.777–0.881), 0.850 (0.828–0.882), 0.820 (0.783–0.858) and 0.643 (0.546–0.747). Multivariate analysis showed that fatigue, pain, age and financial difficulties had a marked negative impact on HRQoL.

The mean HRQoL scores of CRC patients varied considerably depending on the HRQoL instrument used, but remained surprisingly good up to the palliative stage. In addition to age- and cancer-related symptoms, financial difficulties also had a clear negative impact on HRQoL, which needs to be taken into consideration when supporting patient HRQoL.

The study investigated whether autophagic activity and hypoxia parallel the adenoma–carcinoma sequence.

The study comprised 120 tubular adenomas with high-grade dysplasia, including 22 with questionable evidence of invasion, 37 with definite stromal invasion and 29 with severely dysplastic adenoma, 10 traditional serrated adenomas and 22 classical tubular adenomas lacking aggressive features. The samples were stained immunohistochemically for autophagy (LC3A and Beclin-1) and hypoxia-inducible factor1-alpha (HIF1α) markers.

LC3A was detected as diffuse cytoplasmic staining and as dense “stone-like” structures (SLS) within cytoplasmic vacuoles. Beclin-1 reactivity was purely cytoplasmic, whereas that of HIF1α was both cytoplasmic and nuclear. SLS counts in noninvasive, nontransformed areas of tubular adenomas were consistently low (median SLS = 0.5; 200× magnification), whereas a progressive increase was noted from areas of equivocal invasion (median SLS = 1.3; 200× magnification) and intramucosal carcinoma (median SLS = 1.4; 200× magnification) to unequivocal invasive foci (median SLS = 2.1; 200× magnification) (P < 0.0001). A similar association was shown for Beclin-1 and HIF1α expression (P < 0.05). Traditional serrated adenomas yielded low SLS counts and weak HIF1α reactivity, but high cytoplasmic LC3A and Beclin-1 expression (P < 0.01).

A hypoxia-driven autophagy in adenomatous polyps, when particularly intense and localized, is commonly associated with early invasion or severely dysplastic adenoma.

The aim of this study was to investigate the potential of sequential positron emission tomography (PET)/CT standardized uptake value (SUV)/metabolic area variation in predicting the pathological response to preoperative chemoradiotherapy (CRT) for rectal cancer.

Fifty-three patients diagnosed with clinical T3-4 and/or N+ rectal cancer were enrolled. All patients received CRT followed by radical surgery after 6–8 weeks. A PET/CT scan was performed before (PET/CT1) initiation of treatment and a second scan (PET/CT2) was performed within 1 week after the completion of CRT. Thirty-five of 53 patients also underwent a third (PET/CT3) scan within 1 week before surgery. Maximal SUV within the tumour (SUVmax), average SUV within the tumour (SUVmean), metabolic tumour volume (MV), total lesion glycolysis (TLG) and response indices (∆%, i.e. the percentage difference between two different PET/CT scans for SUVmax, SUVmean, MV and TLG) were calculated. The different metabolic parameters were analysed and correlated with the tumour regression grade (TRG) score.

When patients were regrouped as responders (TRG 3-4) and nonresponders (TRG 0-2), significant differences were observed in the percentage differences between PET/CT1 and PET/CT3 for MV (∆%MV(1-3); 91.08% vs 75.43%) and for TLG (∆%TLG(1-3); 94.00% vs 82.02%). As demonstrated by receiver–operating characteristics analysis, ∆%MV(1-3) and ∆%TLG(1-3) both had a strong capability to discriminate between responders and nonresponders. Patients classified as having a pathological complete response (pCR) and a non-pCR showed significant differences in the percentage difference between PET/CT1 and PET/CT3 in SUVmax (∆% SUVmax(1-3); 69.17% vs 57.77%), SUVmean (∆% SUVmean(1-3); 44.20% vs 30.19%), ∆%MV(1-3) (90.93% vs 80.30%) and ∆%TLG(1-3) (94.22% vs 85.63%). ∆%TLG (1-3) was a more powerful discriminator than the others.

Differences in the SUV/metabolic area with 18F-fluorodeoxyglucose (18^F-FDG) PET/CT have the potential to predict a response to preoperative CRT for rectal cancer.

The aim of the study was to present the largest series of colonic inflammatory myofibroblastic tumour (C-IMFT) in the literature so far and to provide a review of this condition.

A retrospective review was carried out of a consecutive series of patients diagnosed with a C-IMFT at a community-based hospital with a specialized gastrointestinal unit between 2002 and 2011. The main outcome measures were success rate and postoperative complications. Using a set of terms we searched the PubMed database for papers published on C-IMFT. We reviewed the data from these studies and case reports.

There were seven patients with a histopathologically proven C-IMFT. The patients' mean age was 39 ± 11.3 years. Four presented with clinical features of intestinal obstruction of varying severity and three with symptoms of anaemia. Complete surgical resection with end-to-end anastomosis was performed. The gross morphology included polypoidal myxoid tumours that served as a lead point for intussusception in two cases, a whorled mass in two and a circumferential infiltrative tumour in three. Microscopically, all tumours had typical features of IMFT with a variable expression of anaplastic lymphoma kinase (ALK-1) and tumour-free resection margins. All patients were well without local recurrence or metastasis at a mean follow-up of 46.8  ± 11.9 months.

Surgical resection is effective for this rare tumour which mostly behaves in a benign manner. Our review supports the need for patients to be followed up for long periods because of the possibility of metastasis or late recurrence.

Recently there has been an increased interest in using electrical stimulation to regulate gut motility generally and particularly for the treatment of slow-transit constipation. In this preliminary canine study, we aimed to study the effects of colonic electrical stimulation (CES) on colonic motility and transit.

Nine dogs, each equipped with a pair of serosal colon electrodes and a proximal colon cannula were randomized to receive: (i) sham-CES, (ii) long pulse CES (20 cpm, 300 ms, 6 mA) or (iii) pulse train CES (40 Hz, 6 ms, 6 mA). Animals underwent assessment of colonic contractions via manometry, and of colonic transit by inserting 24 radiopaque markers via the colonic cannula and radiographically monitoring the markers at 2, 4 and 6 h following their insertion. The colonic transit was assessed by the geometric centre.

We found that, compared with sham-CES, pulse train CES, but not long pulse CES, significantly increased the overall colonic motility index twofold and accelerated the colonic transit by 104% at 2 h, by 60% at 4 h and by 31% at 6 h (P = 0.01, P = 0.02 and P = 0.03 vs sham-CES at 2, 4 and 6 h, respectively). The accelerating effect of pulse train CES was found to be mediated via both cholinergic and nitrergic pathways.

CES with pulse trains has prokinetic effects on colonic contractions and transit in healthy dogs, mediated via the cholinergic and nitrergic pathways. Further clinical studies are warranted to explore the therapeutic potential of CES for slow colonic transit constipation.

The effect of muscular training, abdominal massage and diaphragmatic breathing was compared with medical treatment in a prospective randomized trial of patients with chronic functional constipation.

Patients aged 4–18 years old with functional constipation according to the Rome III criteria were randomized to physiotherapy or medical treatment. In the physiotherapy group, exercises (isometric training of the abdominal muscles, diaphragmatic breathing exercises and abdominal massage) were employed during 12 40-min sessions twice a week by a trained physiotherapist, with laxatives. Patients in the medication group were only given laxatives. Primary outcome measures were frequency of defaecation and faecal incontinence. The analysis was performed by intention-to-treat.

After 6 weeks of treatment, the frequency of bowel movements was higher in the physiotherapy group [5.1 (2.1) days/week] than in the medication group [3.9 (2.0) days/week] (P = 0.01). The frequency of faecal incontinence was no different between the groups [3.6 (1.9) days/week vs 3.0 (2.1) days/week] (P = 0.31).

The combined use of isometric training of abdominal muscles, breathing exercises and abdominal massage increased defaecation frequency after 6 weeks but faecal incontinence remained unchanged. Physiotherapy may be a useful treatment for constipation.

The use of multimedia information provided preoperatively can potentially reduce anxiety in patients and improve the hospital experience. However, the use of two-dimensional (2D) animation (cartoon) to provide information to patients undergoing colorectal surgery has not been investigated. This study investigated the effect of preoperative 2D information on anxiety and knowledge retention in patients undergoing bowel surgery.

Patients were randomized to one of two groups; the video group watched a 13-min cartoon animation whereas the nonvideo group did not. Anxiety levels were measured at the preadmission clinic, postvideo, on the day of admission for surgery, within 24-h after surgery and before discharge using the Spielberger state-trait anxiety inventory and visual analogue scale. Both groups completed a knowledge retention questionnaire and the video group completed a feedback questionnaire about the animation.

Thirty-one patients (16 video, 15 nonvideo) participated in the study. There was no significant difference in baseline anxiety score between two groups. An immediate reduction (P = 0.03) in anxiety score was observed in the video group after watching the video compared with baseline. There was a significant reduction in anxiety score in the video group at discharge compared with the nonvideo group (P = 0.03). There was no significant difference in knowledge retention between two groups. Eighty-eight per cent of patients who watched the video found it beneficial.

2D animation is an effective medium for delivering information to patients undergoing bowel surgery and can potentially reduce anxiety related to surgery and improve the hospital experience.

The study was performed to determine the prevalence of right-sided diverticular disease in a western population and whether it is more likely to bleed than disease on the left side.

From January 2004 to June 2005, 796 consecutive patients were referred for total colonoscopy to 17 physicians. Data obtained included age, gender, and presence and localization of diverticula. This population was compared with a cohort of 133 consecutive patients who were admitted for colonic diverticular bleeding.

Three-hundred and eighteen (40%) of the 796 patients presented with noncomplicated diverticulosis. Of these, 103 (32.4%) had right-sided diverticula. In univariate analysis, the presence of right diverticula in patients admitted for diverticular bleeding was about twice as frequent as in patients who had diverticula with no bleeding (65.2% vs 32.4%; P = 0.0001). In multivariate analysis, the right localization of the diverticulosis was associated with a risk of bleeding, which was independent of the patients' age (P = 0.0001, OR = 3.6).

The prevalence of colonic diverticula increased from < 10% in adults under 40 years of age to about 75% in those over 75 years of age. Of these patients, nearly one-third presented with right-sided involvement. Right-sided localization was associated with a significant risk of bleeding, which was independent of the patients' age.

Reported incidence rates of colorectal anastomotic leakage (AL) vary between 2.5 and 20%. There is little information on late anastomotic leakage (LAL). The aim of this study was to determine the incidence of LAL after colorectal resection.

All patients undergoing colorectal resection with primary anastomosis between January 2004 and October 2009 at the University Medical Center Groningen were included. LAL was defined as anastomotic leakage diagnosed more than 30 days after surgery.

One hundred and forty-one patients were analysed. Indications for surgery included both benign and malignant conditions. The incidence of early anastomotic leakage (EAL) within 30 days after surgery was 13%. The LAL rate was 6%. Eighty-nine per cent of patients with EAL underwent relaparotomy compared with 44% for LAL (P = 0.02).

One-third of all anastomotic leakages were diagnosed more than 30 days after surgery. Of these, 44% underwent relaparotomy. Patients with leakage diagnosed within 30 days after surgery were more likely to undergo relaparotomy. LAL is a significant problem after colorectal surgery.